2018 Medicare Part D Plan Formulary Information |
Allwell Dual Medicare (HMO SNP) (H5294-002-4)
Benefit Details
|
The Allwell Dual Medicare (HMO SNP) (H5294-002-4) Formulary Drugs Starting with the Letter M in Bexar County, TX: CMS MA Region 17 which includes: TX Plan Monthly Premium: $24.50 Deductible: $50 |
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 |
$100.00 | N/A | None |
Magnesium Cl/ K+ Cl/ Sodium Acetate/ Sodium Cl/ Sodium gluconate pH 7.4 Solution [Physiosol] |
2 |
Generic |
$19.00 | N/A | None |
MAGNESIUM SULFATE 50% VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
3 |
Preferred Brand |
$47.00 | N/A | None |
MALATHION 0.5% LOTION |
3 |
Preferred Brand |
$47.00 | N/A | None |
MAPROTILINE 25MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
MAPROTILINE 50MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
MAPROTILINE 75MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MARLISSA-28 TABLET |
2 |
Generic |
$19.00 | N/A | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MATULANE 50 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | None |
MATZIM LA 180 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MATZIM LA 240 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MATZIM LA 300 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MATZIM LA 360 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MATZIM LA 420 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MAVYRET 100-40 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P |
MECLIZINE 12.5 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MECLIZINE 25 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MEDROL 2 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
1* |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera] |
2 |
Generic |
$19.00 | N/A | None |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
2 |
Generic |
$19.00 | N/A | None |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
1* |
Preferred Generic |
$0.00 | N/A | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
1* |
Preferred Generic |
$0.00 | N/A | None |
MEFENAMIC ACID 250 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MEFLOQUINE HCL 250 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEGESTROL 20 MG TABLET |
2 |
Generic |
$19.00 | N/A | P |
MEGESTROL 40 MG TABLET |
2 |
Generic |
$19.00 | N/A | P |
MEGESTROL 625 MG/5 ML SUSP |
2 |
Generic |
$19.00 | N/A | P |
MEGESTROL ACET 40 MG/ML SUSP |
3 |
Preferred Brand |
$47.00 | N/A | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P |
MELOXICAM 15 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
MELOXICAM 7.5 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
2 |
Generic |
$19.00 | N/A | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Generic |
$19.00 | N/A | P |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda] |
2 |
Generic |
$19.00 | N/A | P |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda] |
2 |
Generic |
$19.00 | N/A | P |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda] |
2 |
Generic |
$19.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda] |
2 |
Generic |
$19.00 | N/A | P |
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 |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MENVEO A-C-Y-W-135-DIP VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MERCAPTOPURINE 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MEROPENEM IV 1 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MESALAMINE 4 GM/60 ML ENEMA |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MESALAMINE 800 MG DR TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
MESNA 1 GRAM/10 ML VIAL |
2 |
Generic |
$19.00 | N/A | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
32% | N/A | None |
Metadate er 20 mg tablet |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:3 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metaxall 800 mg tablet |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
METAXALONE 400 MG TABLET [Skelaxin] |
3 |
Preferred Brand |
$47.00 | N/A | P |
METAXALONE 800 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
METFORMIN HCL 1,000 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METFORMIN HCL 500 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METFORMIN HCL 850 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METFORMIN HCL ER 1,000 MG TAB |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METFORMIN HCL ER 500 MG OSM-TB |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METFORMIN HCL ER 500 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METFORMIN HCL ER 750 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
METHADONE 10 MG/5 ML SOLUTION |
2 |
Generic |
$19.00 | N/A | Q:33 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE 5 MG/5 ML SOLUTION |
2 |
Generic |
$19.00 | N/A | Q:67 /1Days |
METHADONE HCL 10 MG TABLET [Methadose] |
3 |
Preferred Brand |
$47.00 | N/A | Q:7 /1Days |
METHADONE HCL 5 MG TABLET [Methadose] |
3 |
Preferred Brand |
$47.00 | N/A | Q:13 /1Days |
METHAMPHETAMINE 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Methazolamide 25 MG Oral Tablet |
1* |
Preferred Generic |
$0.00 | N/A | None |
METHAZOLAMIDE 50 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
Methenamine Hippurate 1g/1 |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHIMAZOLE 10 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
METHIMAZOLE 5 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
METHOCARBAMOL 500 MG TABLET |
2 |
Generic |
$19.00 | N/A | P |
METHOCARBAMOL 750 MG TABLET |
2 |
Generic |
$19.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
methotrexate 1 gm vial |
2 |
Generic |
$19.00 | N/A | None |
METHOTREXATE 2.5MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHOTREXATE 250 MG/10 ML VIAL |
1* |
Preferred Generic |
$0.00 | N/A | None |
METHOTREXATE 250 MG/10 ML VIAL |
2 |
Generic |
$19.00 | N/A | None |
METHOTREXATE 50 MG/2 ML VIAL |
1* |
Preferred Generic |
$0.00 | N/A | None |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
32% | N/A | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:1 /1Days |
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:2 /1Days |
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:1 /1Days |
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:1 /1Days |
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:1 /1Days |
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta] |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:3 /1Days |
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta] |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHYLPHENIDATE ER 36 MG TABLET ER 24 [Concerta] |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 |
1* |
Preferred Generic |
$0.00 | N/A | None |
methylprednisolone 125 mg vial |
3 |
Preferred Brand |
$47.00 | N/A | None |
Methylprednisolone 125 mg vial |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHYLPREDNISOLONE 16MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHYLPREDNISOLONE 32MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2 |
Generic |
$19.00 | N/A | None |
METHYLPREDNISOLONE 4 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
methylprednisolone 40 mg vial |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylprednisolone 40 mg/ml vl |
1* |
Preferred Generic |
$0.00 | N/A | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
Methylprednisolone acetate 80 MG per 1 ML Injection |
1* |
Preferred Generic |
$0.00 | N/A | None |
METHYLTESTOSTERONE 10 MG CAP |
2 |
Generic |
$19.00 | N/A | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | N/A | None |
METOCLOPRAMIDE 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Generic |
$19.00 | N/A | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
2 |
Generic |
$19.00 | N/A | None |
METOLAZONE 10MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METOLAZONE 2.5MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METOLAZONE 5MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Generic |
$19.00 | N/A | None |
METOPROLOL SUCC ER 200 MG TAB |
2 |
Generic |
$19.00 | N/A | None |
METOPROLOL SUCC ER 25 MG TAB |
2 |
Generic |
$19.00 | N/A | None |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Generic |
$19.00 | N/A | None |
METOPROLOL TARTRATE 100 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
METOPROLOL TARTRATE 25 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1* |
Preferred Generic |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
2 |
Generic |
$19.00 | N/A | None |
METRONIDAZOLE 375 MG CAPSULE [Flagyl] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
2 |
Generic |
$19.00 | N/A | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
2 |
Generic |
$19.00 | N/A | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MEXILETINE 150MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEXILETINE 200MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
MEXILETINE 250MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIACALCIN 400 UNIT/2 ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Microgestin 21 1-20 tablet |
1* |
Preferred Generic |
$0.00 | N/A | None |
MICROGESTIN 21 1.5-30 TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
Microgestin fe 1-20 tablet |
1* |
Preferred Generic |
$0.00 | N/A | None |
MICROGESTIN FE 1.5-30 TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
MIDODRINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MIDODRINE HCL 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MIDODRINE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Migergot suppository |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Miglitol 100 MG TABLET [Glyset] |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
Miglitol 25 MG TABLET [Glyset] |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Miglitol 50 MG TABLET [Glyset] |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Specialty Tier |
32% | N/A | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
5 |
Specialty Tier |
32% | N/A | None |
MILI 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
$19.00 | N/A | None |
MILLIPRED 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MIMVEY 1-0.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
MIMVEY LO 0.5-0.1 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
MINITRAN 0.1 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | None |
MINITRAN 0.2 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | None |
MINITRAN 0.4 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | None |
MINITRAN 0.6 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE 100 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
MINOCYCLINE 50 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
MINOCYCLINE 75 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
MINOCYCLINE HCL 100 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MINOXIDIL 10MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MINOXIDIL 2.5MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MIRTAZAPINE 15 MG ODT |
3 |
Preferred Brand |
$47.00 | N/A | None |
MIRTAZAPINE 15 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MIRTAZAPINE 30 MG ODT |
3 |
Preferred Brand |
$47.00 | N/A | None |
MIRTAZAPINE 30 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mirtazapine 45 mg odt |
3 |
Preferred Brand |
$47.00 | N/A | None |
MIRTAZAPINE 45 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MIRTAZAPINE 7.5 MG TABLET |
2 |
Generic |
$19.00 | N/A | None |
MIRVASO 0.33% GEL PUMP |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
misoprostol 100 mcg tablet |
3 |
Preferred Brand |
$47.00 | N/A | None |
misoprostol 200 mcg tablet |
3 |
Preferred Brand |
$47.00 | N/A | None |
MITOMYCIN 20 MG VIAL |
2 |
Generic |
$19.00 | N/A | None |
MITOMYCIN 40 MG VIAL |
2 |
Generic |
$19.00 | N/A | None |
MITOMYCIN 5 MG VIAL |
2 |
Generic |
$19.00 | N/A | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Generic |
$19.00 | N/A | None |
MODAFINIL 100 MG TABLET [Provigil] |
2 |
Generic |
$19.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MODAFINIL 200 MG TABLET [Provigil] |
2 |
Generic |
$19.00 | N/A | P Q:1 /1Days |
Moderiba 200 mg tablet |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Moexipril hcl 15 mg tablet |
6* |
Select Care Drugs |
$0.00 | N/A | None |
MOEXIPRIL HCL 7.5 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | None |
MOMETASONE FUROATE 0.1% CREAM |
3 |
Preferred Brand |
$47.00 | N/A | None |
MOMETASONE FUROATE 0.1% OINT |
3 |
Preferred Brand |
$47.00 | N/A | None |
MOMETASONE FUROATE 0.1% SOLN |
3 |
Preferred Brand |
$47.00 | N/A | None |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
2 |
Generic |
$19.00 | N/A | 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 |
$47.00 | N/A | None |
MONTELUKAST SOD 4 MG TAB CHEW [Singulair] |
3 |
Preferred Brand |
$47.00 | N/A | None |
MONTELUKAST SOD 5 MG TAB CHEW [Singulair] |
3 |
Preferred Brand |
$47.00 | N/A | None |
MORGIDOX 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MORPHINE SULF 20 MG/5 ML SOLN |
3 |
Preferred Brand |
$47.00 | N/A | Q:50 /1Days |
MORPHINE SULF ER 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:2 /1Days |
MORPHINE SULF ER 15 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:13 /1Days |
MORPHINE SULF ER 200 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:2 /1Days |
MORPHINE SULF ER 30 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:7 /1Days |
MORPHINE SULF ER 60 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:3 /1Days |
MORPHINE SULFATE 100 mg/5 ml soln |
3 |
Preferred Brand |
$47.00 | N/A | Q:10 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
3 |
Preferred Brand |
$47.00 | N/A | Q:100 /1Days |
MORPHINE SULFATE ER 10 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:20 /1Days |
MORPHINE SULFATE ER 100 MG CAP |
5 |
Specialty Tier |
32% | N/A | Q:2 /1Days |
MORPHINE SULFATE ER 20 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:10 /1Days |
MORPHINE SULFATE ER 30 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:7 /1Days |
MORPHINE SULFATE ER 50 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:4 /1Days |
MORPHINE SULFATE ER 60 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:3 /1Days |
MORPHINE SULFATE ER 80 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:3 /1Days |
MOVANTIK 12.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MOVANTIK 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MOXIFLOXACIN 0.5% EYE DROPS |
2 |
Generic |
$19.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOZOBIL 20 MG/ML VIAL |
5 |
Specialty Tier |
32% | N/A | P |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$47.00 | N/A | None |
MUPIROCIN 2% CREAM |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MUPIROCIN 2% OINTMENT |
2 |
Generic |
$19.00 | N/A | None |
MUSTARGEN 10 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
5 |
Specialty Tier |
32% | N/A | None |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
5 |
Specialty Tier |
32% | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
32% | N/A | P |
MYCOPHENOLATE 250 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
3 |
Preferred Brand |
$47.00 | N/A | P |
Mycophenolate 500 mg vial |
2 |
Generic |
$19.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLIC ACID DR 180 MG TB |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
MYCOPHENOLIC ACID DR 360 MG TB |
2 |
Generic |
$19.00 | N/A | P |
Mylotarg 5 mg/5mL 5 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
32% | N/A | None |
MYORISAN 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MYORISAN 20 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Myorisan 30 mg capsule |
2 |
Generic |
$19.00 | N/A | None |
MYORISAN 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |