2019 Medicare Part D Plan Formulary Information |
Prime Health Complete (HMO SNP) (H2926-001-0)
Benefit Details
|
The Prime Health Complete (HMO SNP) (H2926-001-0) Formulary Drugs Starting with the Letter M in Grant County, MN: CMS MA Region 19 which includes: MN Plan Monthly Premium: $27.30 Deductible: $415 |
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 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MAGNESIUM SULFATE 50% VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MALATHION 0.5% LOTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MAPROTILINE 25MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MAPROTILINE 50MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MAPROTILINE 75MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MARLISSA-28 TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MARPLAN 10MG TABLET (100 CT) |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MATULANE 50 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAVYRET 100-40 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P Q:84 /28Days |
MAYZENT 0.25 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P Q:112 /28Days |
MAYZENT 2 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P Q:30 /30Days |
MECLIZINE 12.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MECLIZINE 25 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:1 /84Days |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:1 /84Days |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEFENAMIC ACID 250 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEFLOQUINE HCL 250 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEGESTROL 20 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MEGESTROL 40 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MEGESTROL ACET 40 MG/ML SUSP |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MEKINIST 0.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P Q:90 /30Days |
MEKINIST 2 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P Q:30 /30Days |
MEKTOVI 15 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P Q:180 /30Days |
MELOXICAM 15 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MELOXICAM 7.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEMANTINE HCL 5 MG TABLET [Namenda] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
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 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MENEST 0.3MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MENEST 0.625MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MENEST 1.25MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MENVEO A-C-Y-W-135-DIP VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MERCAPTOPURINE 50 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEROPENEM 500MG/VIAL FOR INJECTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEROPENEM IV 1 GM VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MESALAMINE 1,000 MG SUPP.RECT [Canasa] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MESALAMINE 800 MG DR TABLET DR [Asacol HD] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MESNEX 400MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METAPROTERENOL 10MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METAPROTERENOL 20MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METFORMIN HCL 1,000 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:75 /30Days |
METFORMIN HCL 500 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL 850 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
METFORMIN HCL ER 500 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
METHADONE 10 MG/5 ML SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:600 /30Days |
METHADONE 5 MG/5 ML SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:1200 /30Days |
METHADONE HCL 10 MG TABLET [Methadose] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
METHADONE HCL 5 MG TABLET [Methadose] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:180 /30Days |
Methenamine Hippurate 1g/1 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHOCARBAMOL 500 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOCARBAMOL 750 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
METHOTREXATE 2.5MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P S |
METHOTREXATE 250 MG/10 ML VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
METHOTREXATE 50 MG/2 ML VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Methoxsalen 10 mg Capsule [8-MOP] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:900 /30Days |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:900 /30Days |
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
METHYLPREDNISOLONE 16MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHYLPREDNISOLONE 4 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL SUCC ER 200 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 25 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL SUCC ER 50 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL TARTRATE 100 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL TARTRATE 25 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEXILETINE 150MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEXILETINE 200MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MEXILETINE 250MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MICONAZOLE 3 200MG SUPPOS. |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Microgestin 21 1-20 tablet |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MICROGESTIN 21 1.5-30 TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Microgestin fe 1-20 tablet |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MICROGESTIN FE 1.5-30 TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIDODRINE HCL 10 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIDODRINE HCL 2.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIDODRINE HCL 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
MILI 0.25-0.035 MG TABLET [VyLibra] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIMVEY LO 0.5-0.1 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MINITRAN 0.1 MG/HR PATCH |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MINITRAN 0.2 MG/HR PATCH |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MINITRAN 0.4 MG/HR PATCH |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINITRAN 0.6 MG/HR PATCH |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MINOCYCLINE 100 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MINOCYCLINE 50 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MINOCYCLINE 75 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MINOXIDIL 10MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MINOXIDIL 2.5MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIRTAZAPINE 15 MG ODT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIRTAZAPINE 15 MG TABLET [Remeron] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIRTAZAPINE 30 MG ODT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIRTAZAPINE 30 MG TABLET [Remeron] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Mirtazapine 45 mg odt |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 45 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MIRTAZAPINE 7.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
misoprostol 100 mcg tablet |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
misoprostol 200 mcg tablet |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MOLINDONE HCL 10 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:240 /30Days |
MOLINDONE HCL 25 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:270 /30Days |
MOLINDONE HCL 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MOMETASONE FUROATE 0.1% OINT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MOMETASONE FUROATE 0.1% SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MONDOXYNE NL 100 MG CAPSULE [Monodox] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MONTELUKAST SOD 4 MG TAB CHEW [Singulair] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MONTELUKAST SOD 5 MG TAB CHEW [Singulair] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MORPHINE 10 MG/ML SYRINGE [Infumorph] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MORPHINE SULF 10 MG/5 ML Solution [MSIR] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:700 /30Days |
MORPHINE SULF 20 MG/5 ML Solution [MSIR] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:300 /30Days |
MORPHINE SULF ER 100 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
MORPHINE SULF ER 15 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
MORPHINE SULF ER 200 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
MORPHINE SULF ER 30 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULF ER 60 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:60 /30Days |
MORPHINE SULFATE 100 mg/5 ml soln |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:180 /30Days |
MORPHINE SULFATE 15MG TABLETS |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:180 /30Days |
MORPHINE SULFATE 30MG TABLETS |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
MOVANTIK 12.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MOVANTIK 25 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MOXIFLOXACIN 0.5% EYE DROPS |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MULPLETA 3 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MUPIROCIN 2% OINTMENT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MYCOPHENOLATE 250 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
MYRBETRIQ ER 25 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
MYRBETRIQ ER 50 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |