2020 Medicare Part D Plan Formulary Information |
Allwell Dual Medicare Essentials (HMO D-SNP) (H5117-005-0)
Benefit Details
|
The Allwell Dual Medicare Essentials (HMO D-SNP) (H5117-005-0) Formulary Drugs Starting with the Letter M in Livingston Parish, LA: CMS MA Region 16 which includes: LA Plan Monthly Premium: $32.20 Deductible: $360 |
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 |
Tier 4 |
$100.00 | $300.00 | None |
MAGNESIUM SULFATE 50% VIAL |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MALATHION 0.5% LOTION |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MAPROTILINE 25MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MAPROTILINE 50MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MARLISSA-28 TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MATULANE 50 MG CAPSULE |
5 |
Tier 5 |
26% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MATZIM LA 180 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MATZIM LA 240 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MATZIM LA 300 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MATZIM LA 360 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MATZIM LA 420 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MAVENCLAD 10 MG X 10 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
MAVENCLAD 10 MG X 4 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
MAVENCLAD 10 MG X 5 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
MAVENCLAD 10 MG X 6 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
MAVENCLAD 10 MG X 7 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
MAVENCLAD 10 MG X 8 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAVENCLAD 10 MG X 9 TABLET PK |
5 |
Tier 5 |
26% | N/A | P |
MAVYRET 100-40 MG TABLET |
5 |
Tier 5 |
26% | N/A | P |
MAYZENT 0.25 MG TABLET |
5 |
Tier 5 |
26% | N/A | P |
MAYZENT 2 MG TABLET |
5 |
Tier 5 |
26% | N/A | P |
MECLIZINE 12.5 MG TABLET [Antivert] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MECLIZINE 25 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MEDROL 2 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 150 MG/ML SYRINGE [Depo-Provera] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MEFENAMIC ACID 250 MG CAPSULE [Ponstel] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MEFLOQUINE HCL 250 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MEGESTROL 20 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEGESTROL 40 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEGESTROL 625 MG/5 ML ORAL SUSPENSION [Megace ES] |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEGESTROL ACET 40 MG/ML SUSP |
3 |
Tier 3 |
$47.00 | $141.00 | P |
MEKINIST 0.5 MG TABLET |
5 |
Tier 5 |
26% | N/A | P |
MEKINIST 2 MG TABLET |
5 |
Tier 5 |
26% | N/A | P |
MEKTOVI 15 MG TABLET |
5 |
Tier 5 |
26% | N/A | P |
MELOXICAM 15 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MELOXICAM 7.5 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Tier 2 |
$7.00 | $21.00 | 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 |
Tier 4 |
$100.00 | $300.00 | None |
MENVEO A-C-Y-W-135-DIP VIAL |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MERCAPTOPURINE 50 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MEROPENEM IV 1 GM VIAL [Merrem] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MEROPENEM IV 500 MG VIAL [Merrem] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MESALAMINE 4 GM/60 ML ENEMA |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MESALAMINE 800 MG DR TABLET DR [Asacol HD] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MESALAMINE DR 1.2 GM TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MESALAMINE ER 0.375 GRAM CAPSULE 24H [Apriso] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MESNEX 400MG TABLET |
5 |
Tier 5 |
26% | N/A | None |
METAXALONE 400 MG TABLET [Skelaxin] |
3 |
Tier 3 |
$47.00 | $141.00 | P |
METAXALONE 800 MG TABLET [Skelaxin] |
4 |
Tier 4 |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL 1,000 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
METFORMIN HCL 500 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
METFORMIN HCL 850 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
METFORMIN HCL ER 500 MG TABLET ER 24H [Prozac] |
6* |
Tier 6 |
$0.00 | $0.00 | None |
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR] |
6* |
Tier 6 |
$0.00 | $0.00 | None |
METHADONE 10 MG/5 ML SOLUTION |
3 |
Tier 3 |
$47.00 | $141.00 | Q:33 /1Days |
METHADONE 5 MG/5 ML SOLUTION |
3 |
Tier 3 |
$47.00 | $141.00 | Q:15 /1Days |
METHADONE HCL 10 MG TABLET [Methadose] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:6 /1Days |
METHADONE HCL 5 MG TABLET [Methadose] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:6 /1Days |
METHAMPHETAMINE 5 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | P |
METHAZOLAMIDE 25 MG TABLET [Neptazane] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHAZOLAMIDE 50 MG TABLET [Neptazane] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
METHENAMINE HIPP 1 GM TABLET [Urex] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METHOCARBAMOL 500 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | P |
METHOCARBAMOL 750 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | P |
METHOTREXATE 2.5 MG TABLET [Rheumatrex] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHOTREXATE 50 MG/2 ML VIAL |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METHOTREXATE 50 MG/2 ML VIAL |
2 |
Tier 2 |
$7.00 | $21.00 | None |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Tier 5 |
26% | N/A | None |
METHSCOPOLAMINE BROM 2.5 MG TABLET [Pamine] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROM 5 MG TABLET [Pamine Forte] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:2 /1Days |
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
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] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE ER 36 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHYLPHENIDATE ER 36 MG TABLET ER 24 [Concerta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE ER(CD) 30MG CAPSULE CPBP 30-70 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE ER(LA) 10MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE ER(LA) 40MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE LA 30 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 [Ritalin LA] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 16 MG TABLET [Medrol Dosepak] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHYLPREDNISOLONE 32 MG TABLET [Medrol] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METHYLPREDNISOLONE 4 MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHYLPREDNISOLONE 8 MG TABLET [Medrol] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METHYLTESTOSTERONE 10 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $21.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLUTION |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METOLAZONE 10MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METOLAZONE 2.5MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 5MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METOPROLOL SUCC ER 100 MG TABLET ER 24H [Toprol XL] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METOPROLOL SUCC ER 200 MG TABLET 24H [Toprol XL] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METOPROLOL SUCC ER 25 MG TABLET 24H [Toprol XL] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METOPROLOL TARTRATE 100 MG TABLET [Lopressor] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 25 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL-HCTZ 100-25 MG TABLET [Lopressor HCT] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
3 |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 0.75% CREAM (g) [Vitazol] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METRONIDAZOLE 375 MG CAPSULE [Flagyl] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MEXILETINE 150MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MEXILETINE 200MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 250MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MICAFUNGIN 100 MG VIAL [Mycamine] |
5 |
Tier 5 |
26% | N/A | None |
MICAFUNGIN 50 MG VIAL [Mycamine] |
5 |
Tier 5 |
26% | N/A | None |
MICROGESTIN 21 1-20 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MICROGESTIN 21 1.5-30 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MICROGESTIN FE 1-20 TABLET [Tarina Fe 1/20] |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MICROGESTIN FE 1.5-30 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
MIDODRINE HCL 10 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MIDODRINE HCL 2.5 MG TABLET [ProAmatine] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MIDODRINE HCL 5 MG TABLET [ProAmatine] |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MIGERGOT 2-100 MG SUPPOSITORY SUPP.RECT |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIGLITOL 100 MG TABLET [Glyset] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
MIGLITOL 25 MG TABLET [Glyset] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
MIGLITOL 50 MG TABLET [Glyset] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Tier 5 |
26% | N/A | None |
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP |
5 |
Tier 5 |
26% | N/A | None |
MILI 0.25-0.035 MG TABLET [VyLibra] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MILLIPRED 5 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MIMVEY 1-0.5 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | P |
MINITRAN 0.1 MG/HR PATCH |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MINITRAN 0.2 MG/HR PATCH |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MINITRAN 0.4 MG/HR PATCH |
3 |
Tier 3 |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINITRAN 0.6 MG/HR PATCH |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MINOCYCLINE 100 MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MINOCYCLINE 50 MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MINOCYCLINE 75 MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MINOCYCLINE HCL 100 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MINOCYCLINE HCL 75 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MINOCYCLINE HYDROCHLORIDE 50 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MINOXIDIL 10MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MINOXIDIL 2.5MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MIRTAZAPINE 15 MG ODT |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MIRTAZAPINE 15 MG TABLET [Remeron] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 30 MG ODT |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MIRTAZAPINE 30 MG TABLET [Remeron] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MIRTAZAPINE 45 MG ODT |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MIRTAZAPINE 45 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MIRTAZAPINE 7.5 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MIRVASO 0.33% GEL PUMP |
4 |
Tier 4 |
$100.00 | $300.00 | P |
MISOPROSTOL 100 MCG TABLET [Cytotec] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MISOPROSTOL 200 MCG TABLET [Cytotec] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MODAFINIL 100 MG TABLET [Provigil] |
3 |
Tier 3 |
$47.00 | $141.00 | P |
MODAFINIL 200 MG TABLET [Provigil] |
3 |
Tier 3 |
$47.00 | $141.00 | P Q:1 /1Days |
MOEXIPRIL HCL 15 MG TABLET [Univasc] |
6* |
Tier 6 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOEXIPRIL HCL 7.5 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
MOLINDONE HCL 10 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MOLINDONE HCL 25 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MOLINDONE HCL 5 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MOMETASONE FUROATE 0.1% OINTMENT |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MOMETASONE FUROATE 0.1% SOLUTION |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MONDOXYNE NL 100 MG CAPSULE [Monodox] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MONDOXYNE NL 75 MG CAPSULE [NutriDox] |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
2 |
Tier 2 |
$7.00 | $21.00 | Q:1 /1Days |
MONTELUKAST SOD 4 MG CHEWABLE TABLET [Singulair] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MONTELUKAST SOD 5 MG CHEWABLE TABLET [Singulair] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:1 /1Days |
MORPHINE SULF 10 MG/5 ML Solution [MSIR] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:100 /1Days |
MORPHINE SULF 20 MG/5 ML SOLUTION [MSIR] |
3 |
Tier 3 |
$47.00 | $141.00 | Q:50 /1Days |
MORPHINE SULF ER 100 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:2 /1Days |
MORPHINE SULF ER 15 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULF ER 200 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:2 /1Days |
MORPHINE SULF ER 30 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULF ER 60 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULFATE 100 MG/5 ML SOLUTION |
3 |
Tier 3 |
$47.00 | $141.00 | Q:10 /1Days |
MORPHINE SULFATE ER 10 MG CAPSULE |
3 |
Tier 3 |
$47.00 | $141.00 | Q:3 /1Days |
MORPHINE SULFATE ER 100 MG CAPSULE |
5 |
Tier 5 |
26% | N/A | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE ER 20 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULFATE ER 30 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULFATE ER 50 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULFATE ER 60 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULFATE ER 80 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | Q:3 /1Days |
MORPHINE SULFATE IR 15 MG TABLET [MSIR] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:13 /1Days |
MORPHINE SULFATE IR 30 MG TABLET [MSIR] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:13 /1Days |
MOVANTIK 12.5 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MOVANTIK 25 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MOXIFLOXACIN 0.5% EYE DROPS [Vigamox] |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MULPLETA 3 MG TABLET |
5 |
Tier 5 |
26% | 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 |
3 |
Tier 3 |
$47.00 | $141.00 | None |
MUPIROCIN 2% CREAM (g) [Bactroban] |
4 |
Tier 4 |
$100.00 | $300.00 | Q:1 /1Days |
MUPIROCIN 2% OINTMENT [Centany AT] |
2 |
Tier 2 |
$7.00 | $21.00 | Q:1 /1Days |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
5 |
Tier 5 |
26% | N/A | None |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Tier 5 |
26% | N/A | P |
MYCOPHENOLATE 250 MG CAPSULE [CellCept] |
3 |
Tier 3 |
$47.00 | $141.00 | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
3 |
Tier 3 |
$47.00 | $141.00 | P |
MYCOPHENOLIC ACID DR 180 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | P |
MYCOPHENOLIC ACID DR 360 MG TABLET |
2 |
Tier 2 |
$7.00 | $21.00 | P |
MYORISAN 10 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MYORISAN 20 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Myorisan 30 mg capsule |
2 |
Tier 2 |
$7.00 | $21.00 | None |
MYORISAN 40 MG CAPSULE |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MYRBETRIQ ER 25 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |
MYRBETRIQ ER 50 MG TABLET |
4 |
Tier 4 |
$100.00 | $300.00 | None |