2019 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-286-0)
Benefit Details
|
The Aetna Medicare Rx Select (PDP) (S5810-286-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $17.10 Deductible: $365 Qualifies for LIS: No |
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 |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Macrobid 25; 75mg/1; mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MAFENIDE ACETATE 50 GM POWD PK PACKET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MAGNESIUM SULFATE 50% VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
4 |
Non-Preferred Drug |
40% | 40% | None |
MALATHION 0.5% LOTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
MAPROTILINE 25MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MAPROTILINE 50MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MAPROTILINE 75MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MARLISSA-28 TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | 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 |
40% | 40% | Q:180 /30Days |
MATULANE 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
MATZIM LA 180 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MATZIM LA 240 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MATZIM LA 300 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MATZIM LA 360 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MATZIM LA 420 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MAVYRET 100-40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
MECLIZINE 12.5 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MECLIZINE 25 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
2* |
Generic |
$2.00 | $6.00 | 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] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
2* |
Generic |
$2.00 | $6.00 | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
2* |
Generic |
$2.00 | $6.00 | None |
MEFLOQUINE HCL 250 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MEGESTROL 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
MEGESTROL 40 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
MEGESTROL 625 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEGESTROL ACET 40 MG/ML SUSP |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEKTOVI 15 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
MELODETTA 24 FE CHEWABLE TAB [Minastrin] |
3 |
Preferred Brand |
$47.00 | $141.00 | 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 |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:98 /365Days |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:360 /30Days |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda] |
4 |
Non-Preferred Drug |
40% | 40% | 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 XR] |
4 |
Non-Preferred Drug |
40% | 40% | 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 |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MENVEO A-C-Y-W-135-DIP VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MEPERIDINE 100 MG TABLET [Meperitab] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:120 /30Days |
MEPERIDINE 100 MG/ML VIAL [Demerol] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEPERIDINE 25 MG/ML VIAL [Demerol] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEPERIDINE 50 MG TABLET [Meperitab] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:120 /30Days |
MEPERIDINE 50 MG/5 ML SOLUTION [Demerol] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:3600 /30Days |
MEPERIDINE 50 MG/ML VIAL [Demerol] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEPROBAMATE 200 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P |
MEPROBAMATE 400 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MERCAPTOPURINE 50 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEROPENEM IV 1 GM VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
MESALAMINE 1,000 MG SUPP.RECT [Canasa] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MESALAMINE 4 GM/60 ML ENEMA |
4 |
Non-Preferred Drug |
40% | 40% | Q:1680 /28Days |
MESALAMINE 800 MG DR TABLET DR [Asacol HD] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MESALAMINE DR 1.2 GM TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
Metadate er 20 mg tablet |
4 |
Non-Preferred Drug |
40% | 40% | P Q:90 /30Days |
METAPROTERENOL 10MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
METAPROTERENOL 20MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | 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 |
$2.00 | $6.00 | 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 500 MG OSM-TB |
4 |
Non-Preferred Drug |
40% | 40% | P Q:150 /30Days |
METFORMIN HCL ER 500 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR] |
2* |
Generic |
$2.00 | $6.00 | None |
Metformin HCL ER tab 500mg |
4 |
Non-Preferred Drug |
40% | 40% | P Q:150 /30Days |
METHADONE 10 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3000 /30Days |
METHADONE 5 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3000 /30Days |
METHADONE HCL 10 MG TABLET [Methadose] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HCL 5 MG TABLET [Methadose] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:180 /30Days |
Methazolamide 25 MG Oral Tablet |
4 |
Non-Preferred Drug |
40% | 40% | None |
METHAZOLAMIDE 50 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
Methenamine Hippurate 1g/1 |
4 |
Non-Preferred Drug |
40% | 40% | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
2* |
Generic |
$2.00 | $6.00 | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
2* |
Generic |
$2.00 | $6.00 | None |
METHOTREXATE 2.5MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METHOTREXATE 250 MG/10 ML VIAL |
2* |
Generic |
$2.00 | $6.00 | None |
METHOTREXATE 50 MG/2 ML VIAL |
2* |
Generic |
$2.00 | $6.00 | None |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
25% | N/A | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
4 |
Non-Preferred Drug |
40% | 40% | None |
METHYLDOPA 250 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P |
METHYLDOPA 500 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P |
METHYLPHENIDATE 10 MG CHEW TABLET [Methylin] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days |
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:900 /30Days |
METHYLPHENIDATE 2.5 MG CHEW TABLET [Methylin] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days |
METHYLPHENIDATE 5 MG CHEW TABLET [Methylin] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days |
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:1800 /30Days |
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 |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE ER 10 MG TABLET [Methylin] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:90 /30Days |
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:90 /30Days |
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE ER 36 MG TAB |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE ER 72 MG TABLET ER 24 [RELEXXII] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
METHYLPREDNISOLONE 16MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2* |
Generic |
$2.00 | $6.00 | None |
METHYLPREDNISOLONE 4 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | 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 |
$2.00 | $6.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
2* |
Generic |
$2.00 | $6.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
40% | 40% | None |
METOCLOPRAMIDE HCL 10 MG ODT |
4 |
Non-Preferred Drug |
40% | 40% | None |
METOCLOPRAMIDE HCL 5 MG ODT |
4 |
Non-Preferred Drug |
40% | 40% | None |
METOLAZONE 10MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
METOLAZONE 2.5MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
METOLAZONE 5MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2* |
Generic |
$2.00 | $6.00 | None |
METOPROLOL SUCC ER 200 MG TAB |
2* |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 25 MG TAB |
2* |
Generic |
$2.00 | $6.00 | None |
METOPROLOL SUCC ER 50 MG TAB |
2* |
Generic |
$2.00 | $6.00 | 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 TABLET FILM COATED 50MG (1000 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol] |
4 |
Non-Preferred Drug |
40% | 40% | None |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
4 |
Non-Preferred Drug |
40% | 40% | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 375 MG CAPSULE [Flagyl] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
4 |
Non-Preferred Drug |
40% | 40% | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
4 |
Non-Preferred Drug |
40% | 40% | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
4 |
Non-Preferred Drug |
40% | 40% | None |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEXILETINE 150MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEXILETINE 200MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MEXILETINE 250MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MIBELAS 24 FE CHEWABLE TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MICONAZOLE 3 200MG SUPPOS. |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICORT HC 2.5% CREAM |
4 |
Non-Preferred Drug |
40% | 40% | Q:28 /30Days |
Microgestin 21 1-20 tablet |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MICROGESTIN 21 1.5-30 TAB |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Microgestin fe 1-20 tablet |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MICROGESTIN FE 1.5-30 TAB |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MIDODRINE HCL 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MIDODRINE HCL 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MIDODRINE HCL 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Specialty Tier |
25% | N/A | P |
MILI 0.25-0.035 MG TABLET [VyLibra] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MIMVEY 1-0.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIMVEY LO 0.5-0.1 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
MINITRAN 0.1 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MINITRAN 0.2 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MINITRAN 0.4 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MINITRAN 0.6 MG/HR PATCH |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MINOCYCLINE 100 MG CAPSULE |
2* |
Generic |
$2.00 | $6.00 | None |
MINOCYCLINE 50 MG CAPSULE |
2* |
Generic |
$2.00 | $6.00 | None |
MINOCYCLINE 75 MG CAPSULE |
2* |
Generic |
$2.00 | $6.00 | None |
MINOCYCLINE ER 105 MG TABLET ER 24H [Solodyn] |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE ER 115 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | S |
Minocycline er 45 mg tablet |
4 |
Non-Preferred Drug |
40% | 40% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE ER 55 MG TABLET ER 24H [Solodyn] |
5 |
Specialty Tier |
25% | N/A | S |
MINOCYCLINE ER 65 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE ER 80 MG TABLET ER 24H [Solodyn] |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE HCL 100 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE HCL 75 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE HYDROCHLORIDE TABLETS ER 135MG |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOCYCLINE HYDROCHLORIDE TABLETS ER 90MG |
4 |
Non-Preferred Drug |
40% | 40% | S |
MINOXIDIL 10MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MINOXIDIL 2.5MG TABLET |
2* |
Generic |
$2.00 | $6.00 | None |
MIRTAZAPINE 15 MG ODT |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 15 MG TABLET [Remeron] |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
MIRTAZAPINE 30 MG ODT |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
MIRTAZAPINE 30 MG TABLET [Remeron] |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
Mirtazapine 45 mg odt |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
MIRTAZAPINE 45 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
MIRTAZAPINE 7.5 MG TABLET |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
misoprostol 100 mcg tablet |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
misoprostol 200 mcg tablet |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MITIGARE 0.6 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
MODAFINIL 100 MG TABLET [Provigil] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:30 /30Days |
MODAFINIL 200 MG TABLET [Provigil] |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
MOLINDONE HCL 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOLINDONE HCL 25 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOLINDONE HCL 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOMETASONE FUROATE 0.1% OINT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOMETASONE FUROATE 0.1% SOLUTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOMETASONE FUROATE 50 MCG SPRY |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:34 /30Days |
MONDOXYNE NL 100 MG CAPSULE [Monodox] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MONDOXYNE NL 75 MG CAPSULE [NutriDox] |
4 |
Non-Preferred Drug |
40% | 40% | 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 |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
MONTELUKAST SOD 4 MG GRANULES [Singulair] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
MONTELUKAST SOD 4 MG TAB CHEW [Singulair] |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
MONTELUKAST SOD 5 MG TAB CHEW [Singulair] |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
MONUROL 3 GM SACHET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MORGIDOX 50 MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MORPHINE 10 MG/ML SYRINGE [Infumorph] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MORPHINE 2 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
40% | 40% | P |
MORPHINE 4 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
40% | 40% | P |
MORPHINE 5 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE 8 MG/ML SYRINGE [Duramorph] |
4 |
Non-Preferred Drug |
40% | 40% | P |
MORPHINE SULF 10 MG/5 ML Solution [MSIR] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:1800 /30Days |
MORPHINE SULF 20 MG/5 ML Solution [MSIR] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days |
MORPHINE SULF ER 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
MORPHINE SULF ER 15 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days |
MORPHINE SULF ER 200 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
MORPHINE SULF ER 30 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
MORPHINE SULF ER 60 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:60 /30Days |
MORPHINE SULFATE 100 mg/5 ml soln |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days |
MORPHINE SULFATE 15MG TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
MORPHINE SULFATE 30MG TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 10 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 100 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 120 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
MORPHINE SULFATE ER 20 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
MORPHINE SULFATE ER 30 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 45 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
MORPHINE SULFATE ER 50 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
MORPHINE SULFATE ER 60 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 75 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 80 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
MORPHINE SULFATE ER 90 MG CAP |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
MOVANTIK 12.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
MOVANTIK 25 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
4 |
Non-Preferred Drug |
40% | 40% | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOXIFLOXACIN 0.5% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.] |
4 |
Non-Preferred Drug |
40% | 40% | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MUPIROCIN 2% CREAM |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUPIROCIN 2% OINTMENT |
2* |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION |
5 |
Specialty Tier |
25% | N/A | None |
MYCAMINE 50MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
25% | N/A | P |
MYCOPHENOLATE 250 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
MYCOPHENOLIC ACID DR 180 MG TB |
4 |
Non-Preferred Drug |
40% | 40% | P |
MYCOPHENOLIC ACID DR 360 MG TB |
4 |
Non-Preferred Drug |
40% | 40% | P |
MYORISAN 10 MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MYORISAN 20 MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
Myorisan 30 mg capsule |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYORISAN 40 MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |