2019 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-290-0)
Benefit Details
|
The Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-290-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $21.90 Deductible: $415 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 |
4 |
Non-Preferred Drug |
49% | 49% | Q:2 /365Days |
MAFENIDE ACETATE 50 GM POWD PK PACKET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MAGNESIUM SULFATE 50% VIAL |
4 |
Non-Preferred Drug |
49% | 49% | P |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
4 |
Non-Preferred Drug |
49% | 49% | P |
MALATHION 0.5% LOTION |
4 |
Non-Preferred Drug |
49% | 49% | None |
MAPROTILINE 25MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
MAPROTILINE 50MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
MAPROTILINE 75MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
MARLISSA-28 TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
49% | 49% | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MATULANE 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
MATZIM LA 180 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MATZIM LA 240 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MATZIM LA 300 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MATZIM LA 360 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MATZIM LA 420 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MECLIZINE 12.5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MECLIZINE 25 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
2* |
Generic |
$3.00 | $6.00 | None |
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera] |
4 |
Non-Preferred Drug |
49% | 49% | Q:1 /90Days |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
4 |
Non-Preferred Drug |
49% | 49% | Q:1 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
2* |
Generic |
$3.00 | $6.00 | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
2* |
Generic |
$3.00 | $6.00 | None |
MEFLOQUINE HCL 250 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MEGESTROL 20 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | P |
MEGESTROL 40 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P |
MEGESTROL ACET 40 MG/ML SUSP |
4 |
Non-Preferred Drug |
49% | 49% | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
MEKTOVI 15 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
MELODETTA 24 FE CHEWABLE TAB [Minastrin] |
2* |
Generic |
$3.00 | $6.00 | None |
MELOXICAM 15 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MELOXICAM 7.5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
3 |
Preferred Brand |
20% | 20% | P Q:49 /28Days |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
20% | 20% | P Q:60 /30Days |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
4 |
Non-Preferred Drug |
49% | 49% | P Q:360 /30Days |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
20% | 20% | P Q:90 /30Days |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR] |
3 |
Preferred Brand |
20% | 20% | P Q:30 /30Days |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda] |
3 |
Preferred Brand |
20% | 20% | P Q:30 /30Days |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda] |
3 |
Preferred Brand |
20% | 20% | P Q:30 /30Days |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR] |
3 |
Preferred Brand |
20% | 20% | P 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 |
4 |
Non-Preferred Drug |
49% | 49% | None |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | P |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | P |
MENVEO A-C-Y-W-135-DIP VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
MERCAPTOPURINE 50 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Drug |
49% | 49% | None |
MEROPENEM IV 1 GM VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
MESALAMINE 4 GM/60 ML ENEMA |
4 |
Non-Preferred Drug |
49% | 49% | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
Metadate er 20 mg tablet |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
METAPROTERENOL 10MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
METAPROTERENOL 20MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | 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 |
4 |
Non-Preferred Drug |
49% | 49% | None |
METFORMIN HCL 1,000 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:60 /30Days |
METFORMIN HCL 500 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:150 /30Days |
METFORMIN HCL 850 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:90 /30Days |
METFORMIN HCL ER 1,000 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
METFORMIN HCL ER 500 MG OSM-TB |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
METFORMIN HCL ER 500 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:120 /30Days |
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR] |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:60 /30Days |
Metformin HCL ER tab 1000mg |
4 |
Non-Preferred Drug |
49% | 49% | S Q:60 /30Days |
Metformin HCL ER tab 500mg |
4 |
Non-Preferred Drug |
49% | 49% | S Q:120 /30Days |
METHADONE 10 MG/5 ML SOLUTION |
2* |
Generic |
$3.00 | $6.00 | Q:450 /30Days |
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 |
$3.00 | $6.00 | Q:600 /30Days |
METHADONE HCL 10 MG TABLET [Methadose] |
2* |
Generic |
$3.00 | $6.00 | Q:120 /30Days |
METHADONE HCL 5 MG TABLET [Methadose] |
2* |
Generic |
$3.00 | $6.00 | Q:180 /30Days |
Methazolamide 25 MG Oral Tablet |
4 |
Non-Preferred Drug |
49% | 49% | None |
METHAZOLAMIDE 50 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
Methenamine Hippurate 1g/1 |
4 |
Non-Preferred Drug |
49% | 49% | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
2* |
Generic |
$3.00 | $6.00 | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
2* |
Generic |
$3.00 | $6.00 | None |
METHOCARBAMOL 500 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | P |
METHOCARBAMOL 750 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | P |
METHOTREXATE 2.5MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOTREXATE 250 MG/10 ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
METHOTREXATE 50 MG/2 ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
Methoxsalen 10 mg Capsule [8-MOP] |
4 |
Non-Preferred Drug |
49% | 49% | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | None |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
METHYLPHENIDATE ER 10 MG TABLET [Methylin] |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta] |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta] |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
METHYLPHENIDATE ER 36 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta] |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
METHYLPREDNISOLONE 16MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2* |
Generic |
$3.00 | $6.00 | None |
METHYLPREDNISOLONE 4 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
2* |
Generic |
$3.00 | $6.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 10MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
METOLAZONE 2.5MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
METOLAZONE 5MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
METOPROLOL SUCC ER 100 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
METOPROLOL SUCC ER 200 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
METOPROLOL SUCC ER 25 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
METOPROLOL SUCC ER 50 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
METOPROLOL TARTRATE 100 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
METOPROLOL TARTRATE 25 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol] |
4 |
Non-Preferred Drug |
49% | 49% | None |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
4 |
Non-Preferred Drug |
49% | 49% | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
2* |
Generic |
$3.00 | $6.00 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
2* |
Generic |
$3.00 | $6.00 | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
4 |
Non-Preferred Drug |
49% | 49% | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
4 |
Non-Preferred Drug |
49% | 49% | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
4 |
Non-Preferred Drug |
49% | 49% | None |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
4 |
Non-Preferred Drug |
49% | 49% | None |
MEXILETINE 150MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 200MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
MEXILETINE 250MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
MIBELAS 24 FE CHEWABLE TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Microgestin 21 1-20 tablet |
2* |
Generic |
$3.00 | $6.00 | None |
MICROGESTIN 21 1.5-30 TAB |
2* |
Generic |
$3.00 | $6.00 | None |
Microgestin fe 1-20 tablet |
2* |
Generic |
$3.00 | $6.00 | None |
MICROGESTIN FE 1.5-30 TAB |
2* |
Generic |
$3.00 | $6.00 | None |
MIDODRINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MIDODRINE HCL 2.5 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MIDODRINE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Specialty Tier |
25% | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MILI 0.25-0.035 MG TABLET [VyLibra] |
2* |
Generic |
$3.00 | $6.00 | None |
MINITRAN 0.1 MG/HR PATCH |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MINITRAN 0.2 MG/HR PATCH |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MINITRAN 0.4 MG/HR PATCH |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MINITRAN 0.6 MG/HR PATCH |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MINOCYCLINE 100 MG CAPSULE |
2* |
Generic |
$3.00 | $6.00 | None |
MINOCYCLINE 50 MG CAPSULE |
2* |
Generic |
$3.00 | $6.00 | None |
MINOCYCLINE 75 MG CAPSULE |
2* |
Generic |
$3.00 | $6.00 | None |
MINOCYCLINE HCL 100 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MINOCYCLINE HCL 75 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOXIDIL 10MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MINOXIDIL 2.5MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MIRTAZAPINE 15 MG ODT |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MIRTAZAPINE 15 MG TABLET [Remeron] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
MIRTAZAPINE 30 MG ODT |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MIRTAZAPINE 30 MG TABLET [Remeron] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
Mirtazapine 45 mg odt |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MIRTAZAPINE 45 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
MIRTAZAPINE 7.5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
misoprostol 100 mcg tablet |
3 |
Preferred Brand |
20% | 20% | None |
misoprostol 200 mcg tablet |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MITIGARE 0.6 MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
Moexipril hcl 15 mg tablet |
2* |
Generic |
$3.00 | $6.00 | None |
MOEXIPRIL HCL 7.5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MOLINDONE HCL 10 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MOLINDONE HCL 25 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MOLINDONE HCL 5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon] |
2* |
Generic |
$3.00 | $6.00 | None |
MOMETASONE FUROATE 0.1% OINT |
2* |
Generic |
$3.00 | $6.00 | None |
MOMETASONE FUROATE 0.1% SOLUTION |
2* |
Generic |
$3.00 | $6.00 | None |
MOMETASONE FUROATE 50 MCG SPRY |
4 |
Non-Preferred Drug |
49% | 49% | S Q:34 /30Days |
MONDOXYNE NL 100 MG CAPSULE [Monodox] |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONDOXYNE NL 75 MG CAPSULE [NutriDox] |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
MONTELUKAST SOD 4 MG GRANULES [Singulair] |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
MONTELUKAST SOD 4 MG TAB CHEW [Singulair] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
MONTELUKAST SOD 5 MG TAB CHEW [Singulair] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
MORGIDOX 50 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
MORPHINE 10 MG/ML SYRINGE [Infumorph] |
4 |
Non-Preferred Drug |
49% | 49% | P Q:240 /30Days |
MORPHINE 2 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
49% | 49% | P Q:1200 /30Days |
MORPHINE 4 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
49% | 49% | P Q:480 /30Days |
MORPHINE 5 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
49% | 49% | P |
MORPHINE 8 MG/ML SYRINGE [Duramorph] |
4 |
Non-Preferred Drug |
49% | 49% | P Q:250 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULF 10 MG/5 ML Solution [MSIR] |
3 |
Preferred Brand |
20% | 20% | Q:700 /30Days |
MORPHINE SULF 20 MG/5 ML Solution [MSIR] |
3 |
Preferred Brand |
20% | 20% | Q:900 /30Days |
MORPHINE SULF ER 100 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
MORPHINE SULF ER 15 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
MORPHINE SULF ER 200 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
MORPHINE SULF ER 30 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
MORPHINE SULF ER 60 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
MORPHINE SULFATE 100 mg/5 ml soln |
3 |
Preferred Brand |
20% | 20% | Q:240 /30Days |
MORPHINE SULFATE 15MG TABLETS |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
MORPHINE SULFATE 30MG TABLETS |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
MOXIFLOXACIN 0.5% EYE DROPS |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.] |
4 |
Non-Preferred Drug |
49% | 49% | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
4 |
Non-Preferred Drug |
49% | 49% | None |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
MUPIROCIN 2% CREAM |
4 |
Non-Preferred Drug |
49% | 49% | None |
MUPIROCIN 2% OINTMENT |
2* |
Generic |
$3.00 | $6.00 | None |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
25% | N/A | P |
MYCOPHENOLATE 250 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
4 |
Non-Preferred Drug |
49% | 49% | P |
MYCOPHENOLIC ACID DR 180 MG TB |
4 |
Non-Preferred Drug |
49% | 49% | P |
MYCOPHENOLIC ACID DR 360 MG TB |
4 |
Non-Preferred Drug |
49% | 49% | P |
MYORISAN 10 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYORISAN 20 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
Myorisan 30 mg capsule |
4 |
Non-Preferred Drug |
49% | 49% | None |
MYORISAN 40 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
MYRBETRIQ ER 25 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
MYRBETRIQ ER 50 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |