2018 Medicare Part D Plan Formulary Information |
Freedom Blue PPO ValueRx (PPO) (H3916-018-0)
Benefit Details
|
The Freedom Blue PPO ValueRx (PPO) (H3916-018-0) Formulary Drugs Starting with the Letter M in Bradford County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $73.00 Deductible: $0 |
Drugs Starting with Letter M
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MAGNESIUM SULFATE 50% VIAL |
2 |
Generic |
$15.00 | $40.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
2 |
Generic |
$15.00 | $40.00 | None |
MAKENA 250 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
MAKENA 275 MG/1.1 ML AUTO INJCT |
5 |
Specialty Tier |
33% | N/A | None |
MALATHION 0.5% LOTION |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MAPROTILINE 25MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MARLISSA-28 TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MATULANE 50 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
MATZIM LA 180 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MATZIM LA 240 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MATZIM LA 300 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MATZIM LA 360 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MATZIM LA 420 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MAVYRET 100-40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:84 /28Days |
MECLIZINE 12.5 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MECLIZINE 25 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MECLOFENAMATE 100MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLOFENAMATE 50MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MEDROL 2 MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
2 |
Generic |
$15.00 | $40.00 | None |
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera] |
2 |
Generic |
$15.00 | $40.00 | None |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
2 |
Generic |
$15.00 | $40.00 | None |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
2 |
Generic |
$15.00 | $40.00 | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
2 |
Generic |
$15.00 | $40.00 | None |
MEFENAMIC ACID 250 MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MEFLOQUINE HCL 250 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MEGESTROL 20 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | P |
MEGESTROL 40 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL 625 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $40.00 | P |
MEGESTROL ACET 40 MG/ML SUSP |
2 |
Generic |
$15.00 | $40.00 | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MELODETTA 24 FE CHEWABLE TAB [Minastrin] |
2 |
Generic |
$15.00 | $40.00 | None |
MELOXICAM 15 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MELOXICAM 7.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MENTAX 1% CREAM |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MENVEO A-C-Y-W-135-DIP VIAL |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MERCAPTOPURINE 50 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MEROPENEM IV 1 GM VIAL |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MESALAMINE 4 GM/60 ML ENEMA |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MESALAMINE 800 MG DR TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MESNA 1 GRAM/10 ML VIAL |
2 |
Generic |
$15.00 | $40.00 | None |
MESNEX 400MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MESTINON 60MG/5ML SYRUP |
5 |
Specialty Tier |
33% | N/A | None |
Metadate er 20 mg tablet |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METAPROTERENOL 10MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $40.00 | None |
Metaxall 800 mg tablet |
2 |
Generic |
$15.00 | $40.00 | None |
METAXALONE 400 MG TABLET [Skelaxin] |
2 |
Generic |
$15.00 | $40.00 | None |
METAXALONE 800 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL 500 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL 850 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL ER 1,000 MG TAB |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P |
METFORMIN HCL ER 500 MG OSM-TB |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P |
METFORMIN HCL ER 500 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METFORMIN HCL ER 750 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE 10 MG/5 ML SOLUTION |
2 |
Generic |
$15.00 | $40.00 | P Q:1033 /31Days |
METHADONE 5 MG/5 ML SOLUTION |
2 |
Generic |
$15.00 | $40.00 | P Q:2066 /31Days |
METHADONE HCL 10 MG TABLET [Methadose] |
2 |
Generic |
$15.00 | $40.00 | P Q:206 /31Days |
METHADONE HCL 200 MG/20 ML VIAL [Dolophine] |
2 |
Generic |
$15.00 | $40.00 | P Q:160 /30Days |
METHADONE HCL 5 MG TABLET [Methadose] |
2 |
Generic |
$15.00 | $40.00 | P Q:248 /31Days |
METHAMPHETAMINE 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Methazolamide 25 MG Oral Tablet |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
METHAZOLAMIDE 50 MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
Methenamine Hippurate 1g/1 |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
METHIMAZOLE 10 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METHIMAZOLE 5 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methotrexate 1 gm vial |
2 |
Generic |
$15.00 | $40.00 | P |
METHOTREXATE 2.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
METHOTREXATE 250 MG/10 ML VIAL |
2 |
Generic |
$15.00 | $40.00 | P |
METHOTREXATE 250 MG/10 ML VIAL |
2 |
Generic |
$15.00 | $40.00 | P |
METHOTREXATE 50 MG/2 ML VIAL |
2 |
Generic |
$15.00 | $40.00 | P |
Methoxsalen 10 mg Capsule [8-MOP] |
2 |
Generic |
$15.00 | $40.00 | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
2 |
Generic |
$15.00 | $40.00 | None |
METHYCLOTHIAZIDE 5MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLDOPA-HCTZ 250-25 MG TABLETt [Aldoril] |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE 10 MG CHEW TABLET [Methylin] |
2 |
Generic |
$15.00 | $40.00 | Q:186 /31Days |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin] |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLPHENIDATE 2.5 MG CHEW TABLET [Methylin] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METHYLPHENIDATE 5 MG CHEW TABLET [Methylin] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin] |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE ER 10 MG TABLET [Methylin] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE ER 36 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:186 /31Days |
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:93 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:62 /31Days |
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA] |
2 |
Generic |
$15.00 | $40.00 | Q:62 /31Days |
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
methylprednisolone 125 mg vial |
2 |
Generic |
$15.00 | $40.00 | None |
Methylprednisolone 125 mg vial |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLPREDNISOLONE 4 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
methylprednisolone 40 mg vial |
2 |
Generic |
$15.00 | $40.00 | None |
Methylprednisolone 40 mg/ml vl |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Methylprednisolone acetate 80 MG per 1 ML Injection |
2 |
Generic |
$15.00 | $40.00 | None |
METHYLTESTOSTERONE 10 MG CAP |
5 |
Specialty Tier |
33% | N/A | P |
Metipranolol 0.3% eye drops |
2 |
Generic |
$15.00 | $40.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $40.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Generic |
$15.00 | $40.00 | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
2 |
Generic |
$15.00 | $40.00 | None |
METOCLOPRAMIDE HCL 10 MG ODT |
2 |
Generic |
$15.00 | $40.00 | None |
METOCLOPRAMIDE HCL 5 MG ODT |
2 |
Generic |
$15.00 | $40.00 | None |
METOLAZONE 10MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 2.5MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METOLAZONE 5MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 200 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 25 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 50 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 100 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 25 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Metoprolol Tartrate 5 ML 1 MG/ML Injection |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
2 |
Generic |
$15.00 | $40.00 | None |
METRONIDAZOLE 375 MG CAPSULE [Flagyl] |
2 |
Generic |
$15.00 | $40.00 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
2 |
Generic |
$15.00 | $40.00 | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
2 |
Generic |
$15.00 | $40.00 | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
2 |
Generic |
$15.00 | $40.00 | None |
MEXILETINE 150MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MEXILETINE 200MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MIACALCIN 400 UNIT/2 ML VIAL |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P |
MIBELAS 24 FE CHEWABLE TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MICONAZOLE 3 200MG SUPPOS. |
2 |
Generic |
$15.00 | $40.00 | None |
Microgestin 21 1-20 tablet |
2 |
Generic |
$15.00 | $40.00 | None |
MICROGESTIN 21 1.5-30 TAB |
2 |
Generic |
$15.00 | $40.00 | None |
Microgestin fe 1-20 tablet |
2 |
Generic |
$15.00 | $40.00 | None |
MICROGESTIN FE 1.5-30 TAB |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 10 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MIDODRINE HCL 2.5 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MIDODRINE HCL 5 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Migergot suppository |
5 |
Specialty Tier |
33% | N/A | None |
Miglitol 100 MG TABLET [Glyset] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
Miglitol 25 MG TABLET [Glyset] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
Miglitol 50 MG TABLET [Glyset] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Specialty Tier |
33% | N/A | P |
MILI 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
$15.00 | $40.00 | None |
MILLIPRED 5 MG TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MINOCYCLINE 100 MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE 50 MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE 75 MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE ER 115 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Minocycline er 45 mg tablet |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE ER 65 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE HCL 100 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE HCL 75 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS ER 135MG |
2 |
Generic |
$15.00 | $40.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS ER 90MG |
2 |
Generic |
$15.00 | $40.00 | None |
MINOXIDIL 10MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOXIDIL 2.5MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MIRCERA 100 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P |
MIRCERA 50 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P |
MIRCERA 75 MCG/0.3 ML SYRINGE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P |
MIRTAZAPINE 15 MG ODT |
2 |
Generic |
$15.00 | $40.00 | None |
MIRTAZAPINE 15 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MIRTAZAPINE 30 MG ODT |
2 |
Generic |
$15.00 | $40.00 | None |
MIRTAZAPINE 30 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Mirtazapine 45 mg odt |
2 |
Generic |
$15.00 | $40.00 | None |
MIRTAZAPINE 45 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
MIRTAZAPINE 7.5 MG TABLET |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
misoprostol 100 mcg tablet |
2 |
Generic |
$15.00 | $40.00 | None |
misoprostol 200 mcg tablet |
2 |
Generic |
$15.00 | $40.00 | None |
MITIGARE 0.6 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $115.00 | Q:62 /31Days |
MITOMYCIN 20 MG VIAL |
2 |
Generic |
$15.00 | $40.00 | None |
MITOMYCIN 40 MG VIAL |
2 |
Generic |
$15.00 | $40.00 | None |
MITOMYCIN 5 MG VIAL |
2 |
Generic |
$15.00 | $40.00 | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MODAFINIL 100 MG TABLET [Provigil] |
2 |
Generic |
$15.00 | $40.00 | P Q:31 /31Days |
MODAFINIL 200 MG TABLET [Provigil] |
2 |
Generic |
$15.00 | $40.00 | P Q:31 /31Days |
Moderiba 200 mg tablet |
2 |
Generic |
$15.00 | $40.00 | None |
Moderiba 400-400 mg dosepack |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Moderiba 600-600 mg dosepack |
2 |
Generic |
$15.00 | $40.00 | None |
Moexipril hcl 15 mg tablet |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL HCL 7.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MOMETASONE FUROATE 0.1% CREAM |
2 |
Generic |
$15.00 | $40.00 | None |
MOMETASONE FUROATE 0.1% OINT |
2 |
Generic |
$15.00 | $40.00 | None |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Generic |
$15.00 | $40.00 | None |
MOMETASONE FUROATE 50 MCG SPRY |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
3 |
Preferred Brand |
$42.00 | $115.00 | Q:31 /31Days |
MONTELUKAST SOD 4 MG GRANULES [Singulair] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
MONTELUKAST SOD 4 MG TAB CHEW [Singulair] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
MONTELUKAST SOD 5 MG TAB CHEW [Singulair] |
2 |
Generic |
$15.00 | $40.00 | Q:31 /31Days |
MONUROL 3 GM SACHET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MORGIDOX 50 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MORPHINE 10 MG/ML ISECURE SYR |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P Q:200 /30Days |
Morphine 2 mg/ml isecure syr |
2 |
Generic |
$15.00 | $40.00 | P Q:1000 /30Days |
Morphine 4 mg/ml isecure syr |
2 |
Generic |
$15.00 | $40.00 | P Q:500 /30Days |
MORPHINE 5 MG/ML SYRINGE |
2 |
Generic |
$15.00 | $40.00 | P Q:400 /30Days |
MORPHINE 8 MG/ML ISECURE SYR |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P Q:250 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULF 20 MG/5 ML SOLN |
2 |
Generic |
$15.00 | $40.00 | P Q:1400 /31Days |
MORPHINE SULF ER 100 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULF ER 15 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:100 /31Days |
MORPHINE SULF ER 200 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:31 /31Days |
MORPHINE SULF ER 30 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:100 /31Days |
MORPHINE SULF ER 60 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:100 /31Days |
MORPHINE SULFATE 100 mg/5 ml soln |
2 |
Generic |
$15.00 | $40.00 | P Q:310 /31Days |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
2 |
Generic |
$15.00 | $40.00 | P Q:2800 /31Days |
MORPHINE SULFATE 15MG TABLETS |
2 |
Generic |
$15.00 | $40.00 | P Q:186 /31Days |
MORPHINE SULFATE 30MG TABLETS |
2 |
Generic |
$15.00 | $40.00 | P Q:186 /31Days |
MORPHINE SULFATE ER 10 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 100 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 120 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:51 /31Days |
MORPHINE SULFATE ER 20 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 30 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 30 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 45 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 50 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 60 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 60 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 75 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MORPHINE SULFATE ER 80 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 90 MG CAP |
3 |
Preferred Brand |
$42.00 | $115.00 | P Q:62 /31Days |
MOVANTIK 12.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | Q:31 /31Days |
MOVANTIK 25 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | Q:31 /31Days |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MOXIFLOXACIN 0.5% EYE DROPS |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
3 |
Preferred Brand |
$42.00 | $115.00 | None |
MOZOBIL 20 MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MUPIROCIN 2% CREAM |
2 |
Generic |
$15.00 | $40.00 | None |
MUPIROCIN 2% OINTMENT |
2 |
Generic |
$15.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUSTARGEN 10 MG VIAL |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
5 |
Specialty Tier |
33% | N/A | P |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
MYCAMINE 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
3 |
Preferred Brand |
$42.00 | $115.00 | P |
MYCOPHENOLATE 250 MG CAPSULE |
2 |
Generic |
$15.00 | $40.00 | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
2 |
Generic |
$15.00 | $40.00 | P |
Mycophenolate 500 mg vial |
3 |
Preferred Brand |
$42.00 | $115.00 | P |
MYCOPHENOLIC ACID DR 180 MG TB |
3 |
Preferred Brand |
$42.00 | $115.00 | P |
MYCOPHENOLIC ACID DR 360 MG TB |
3 |
Preferred Brand |
$42.00 | $115.00 | P |
Mylotarg 5 mg/5mL 5 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYORISAN 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MYORISAN 20 MG CAPSULE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
Myorisan 30 mg capsule |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MYORISAN 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None |
MYRBETRIQ ER 25 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | Q:31 /31Days |
MYRBETRIQ ER 50 MG TABLET |
3 |
Preferred Brand |
$42.00 | $115.00 | Q:31 /31Days |
MYTESI 125 MG DR TABLET |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:62 /31Days |