2019 Medicare Part D Plan Formulary Information |
FHCP Medicare Premier Plus (HMO) (H1035-011-0)
Benefit Details
|
The FHCP Medicare Premier Plus (HMO) (H1035-011-0) Formulary Drugs Starting with the Letter M in Brevard County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 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 |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
MAGNESIUM SULFATE 50% VIAL |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |
MALATHION 0.5% LOTION |
2 |
Generic |
$7.00 | $18.00 | Q:60 /7Days |
MAPROTILINE 25MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | None |
MATULANE 50 MG CAPSULE |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
MAVYRET 100-40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MECLIZINE 25 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 |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
2 |
Generic |
$7.00 | $18.00 | None |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEFLOQUINE HCL 250 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MEGESTROL 20 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MEGESTROL 40 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MEGESTROL ACET 40 MG/ML SUSP |
2 |
Generic |
$7.00 | $18.00 | None |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
MEKTOVI 15 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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] |
2 |
Generic |
$7.00 | $18.00 | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
2 |
Generic |
$7.00 | $18.00 | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Generic |
$7.00 | $18.00 | None |
MEMANTINE HCL 5 MG TABLET [Namenda] |
2 |
Generic |
$7.00 | $18.00 | 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 |
$44.00 | $129.00 | None |
MENEST 0.3MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |
MENEST 0.625MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |
MENEST 1.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |
MENVEO A-C-Y-W-135-DIP VIAL |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEPERIDINE 100 MG TABLET [Meperitab] |
2 |
Generic |
$7.00 | $18.00 | None |
MEPERIDINE 50 MG TABLET [Meperitab] |
2 |
Generic |
$7.00 | $18.00 | None |
MEPROBAMATE 200 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MEPROBAMATE 400 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MERCAPTOPURINE 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
2 |
Generic |
$7.00 | $18.00 | None |
MEROPENEM IV 1 GM VIAL |
2 |
Generic |
$7.00 | $18.00 | None |
MESALAMINE 1,000 MG SUPP.RECT [Canasa] |
2 |
Generic |
$7.00 | $18.00 | Q:30 /30Days |
MESALAMINE 4 GM/60 ML ENEMA |
2 |
Generic |
$7.00 | $18.00 | Q:1680 /28Days |
MESALAMINE 800 MG DR TABLET DR [Asacol HD] |
2 |
Generic |
$7.00 | $18.00 | None |
MESNEX 400MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 10MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$7.00 | $18.00 | 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 TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR] |
2 |
Generic |
$7.00 | $18.00 | None |
METHADONE 5 MG/5 ML SOLUTION |
2 |
Generic |
$7.00 | $18.00 | None |
METHADONE HCL 10 MG TABLET [Methadose] |
2 |
Generic |
$7.00 | $18.00 | None |
METHADONE HCL 5 MG TABLET [Methadose] |
2 |
Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methazolamide 25 MG Oral Tablet |
2 |
Generic |
$7.00 | $18.00 | None |
METHAZOLAMIDE 50 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
2 |
Generic |
$7.00 | $18.00 | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
2 |
Generic |
$7.00 | $18.00 | None |
METHOCARBAMOL 500 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHOCARBAMOL 750 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHOTREXATE 250 MG/10 ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METHOTREXATE 50 MG/2 ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
33% | N/A | None |
METHYLDOPA 250 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLDOPA 500 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin] |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin] |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
2 |
Generic |
$7.00 | $18.00 | Q:93 /31Days |
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPHENIDATE ER 36 MG TAB |
2 |
Generic |
$7.00 | $18.00 | Q:62 /31Days |
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta] |
2 |
Generic |
$7.00 | $18.00 | Q:31 /31Days |
METHYLPREDNISOLONE 16MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPREDNISOLONE 32MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPREDNISOLONE 4 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLN |
2 |
Generic |
$7.00 | $18.00 | None |
METOLAZONE 10MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METOLAZONE 2.5MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METOLAZONE 5MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Generic |
$7.00 | $18.00 | None |
METOPROLOL SUCC ER 200 MG TAB |
2 |
Generic |
$7.00 | $18.00 | None |
METOPROLOL SUCC ER 25 MG TAB |
2 |
Generic |
$7.00 | $18.00 | None |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Generic |
$7.00 | $18.00 | None |
METOPROLOL TARTRATE 100 MG TAB |
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 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 |
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol] |
2 |
Generic |
$7.00 | $18.00 | Q:45 /30Days |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
2 |
Generic |
$7.00 | $18.00 | Q:60 /30Days |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
2 |
Generic |
$7.00 | $18.00 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
2 |
Generic |
$7.00 | $18.00 | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
2 |
Generic |
$7.00 | $18.00 | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
2 |
Generic |
$7.00 | $18.00 | Q:60 /30Days |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
2 |
Generic |
$7.00 | $18.00 | Q:60 /30Days |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
2 |
Generic |
$7.00 | $18.00 | Q:70 /10Days |
MEXILETINE 150MG CAPSULE |
2 |
Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 200MG CAPSULE |
2 |
Generic |
$7.00 | $18.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Generic |
$7.00 | $18.00 | None |
MIDODRINE HCL 10 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MIDODRINE HCL 2.5 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MIDODRINE HCL 5 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
Migergot suppository |
5 |
Specialty Tier |
33% | N/A | Q:12 /14Days |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Specialty Tier |
33% | N/A | P |
MINOCYCLINE 100 MG CAPSULE |
2 |
Generic |
$7.00 | $18.00 | None |
MINOCYCLINE 50 MG CAPSULE |
2 |
Generic |
$7.00 | $18.00 | None |
MINOXIDIL 10MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 15 MG ODT |
2 |
Generic |
$7.00 | $18.00 | None |
MIRTAZAPINE 15 MG TABLET [Remeron] |
2 |
Generic |
$7.00 | $18.00 | None |
MIRTAZAPINE 30 MG ODT |
2 |
Generic |
$7.00 | $18.00 | None |
MIRTAZAPINE 30 MG TABLET [Remeron] |
2 |
Generic |
$7.00 | $18.00 | None |
Mirtazapine 45 mg odt |
2 |
Generic |
$7.00 | $18.00 | None |
MIRTAZAPINE 45 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MIRTAZAPINE 7.5 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
misoprostol 100 mcg tablet |
2 |
Generic |
$7.00 | $18.00 | None |
misoprostol 200 mcg tablet |
2 |
Generic |
$7.00 | $18.00 | None |
MODAFINIL 100 MG TABLET [Provigil] |
2 |
Generic |
$7.00 | $18.00 | P Q:31 /31Days |
MODAFINIL 200 MG TABLET [Provigil] |
2 |
Generic |
$7.00 | $18.00 | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOLINDONE HCL 10 MG TABLET |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
MOLINDONE HCL 25 MG TABLET |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
MOLINDONE HCL 5 MG TABLET |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon] |
2 |
Generic |
$7.00 | $18.00 | Q:120 /30Days |
MOMETASONE FUROATE 0.1% OINT |
2 |
Generic |
$7.00 | $18.00 | Q:120 /30Days |
MOMETASONE FUROATE 0.1% SOLUTION |
2 |
Generic |
$7.00 | $18.00 | Q:60 /30Days |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MONTELUKAST SOD 4 MG GRANULES [Singulair] |
2 |
Generic |
$7.00 | $18.00 | None |
MONTELUKAST SOD 4 MG TAB CHEW [Singulair] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MONTELUKAST SOD 5 MG TAB CHEW [Singulair] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
MORPHINE SULF 10 MG/5 ML Solution [MSIR] |
2 |
Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULF 20 MG/5 ML Solution [MSIR] |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULF ER 100 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULF ER 15 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULF ER 200 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULF ER 30 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULF ER 60 MG TABLET |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULFATE 100 mg/5 ml soln |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULFATE 15MG TABLETS |
2 |
Generic |
$7.00 | $18.00 | None |
MORPHINE SULFATE 30MG TABLETS |
2 |
Generic |
$7.00 | $18.00 | None |
MOVANTIK 12.5 MG TABLET |
3 |
Preferred Brand |
$44.00 | $129.00 | P |
MOVANTIK 25 MG TABLET |
3 |
Preferred Brand |
$44.00 | $129.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
3 |
Preferred Brand |
$44.00 | $129.00 | None |
MOXIFLOXACIN 0.5% EYE DROPS |
2 |
Generic |
$7.00 | $18.00 | None |
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.] |
2 |
Generic |
$7.00 | $18.00 | None |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |
MUPIROCIN 2% OINTMENT |
2 |
Generic |
$7.00 | $18.00 | Q:44 /30Days |
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 |
2 |
Generic |
$7.00 | $18.00 | P |
MYCOPHENOLATE 250 MG CAPSULE |
2 |
Generic |
$7.00 | $18.00 | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
2 |
Generic |
$7.00 | $18.00 | P |
MYCOPHENOLIC ACID DR 180 MG TB |
2 |
Generic |
$7.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLIC ACID DR 360 MG TB |
2 |
Generic |
$7.00 | $18.00 | P |
MYRBETRIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |
MYRBETRIQ ER 50 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P |