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Aetna Medicare Premier (PPO) (H5521-033-0)
Tier 1 (327)
Tier 2 (573)
Tier 3 (919)
Tier 4 (1329)
Tier 5 (660)
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2020 Medicare Part D Plan Formulary Information
Aetna Medicare Premier (PPO) (H5521-033-0)
Benefits & Contact Info           
The Aetna Medicare Premier (PPO) (H5521-033-0)
Formulary Drugs Starting with the Letter M

in Baker County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $300
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 Tier 3 $47.00$141.00None
Macrobid 25; 75mg/1; mg/1 100 CAPSULE BOTTLE   4 Tier 4 $100.00$300.00None
MAFENIDE ACETATE 50 GM POWDER PACKET   4 Tier 4 $100.00$300.00None
MAGNESIUM SULFATE 50% VIAL   4 Tier 4 $100.00$300.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   4 Tier 4 $100.00$300.00None
MALATHION 0.5% LOTION   3 Tier 3 $47.00$141.00None
MAPROTILINE 25MG TABLET   4 Tier 4 $100.00$300.00None
MAPROTILINE 50MG TABLET   4 Tier 4 $100.00$300.00None
MAPROTILINE 75MG TABLET   4 Tier 4 $100.00$300.00None
MARLISSA-28 TABLET   2* Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MARPLAN 10MG TABLET (100 CT)   4 Tier 4 $100.00$300.00Q:180
/30Days
MATULANE 50 MG CAPSULE   5 Tier 5 27%N/ANone
MATZIM LA 180 MG TABLET   2* Tier 2 $0.00$0.00None
MATZIM LA 240 MG TABLET   2* Tier 2 $0.00$0.00None
MATZIM LA 300 MG TABLET   2* Tier 2 $0.00$0.00None
MATZIM LA 360 MG TABLET   2* Tier 2 $0.00$0.00None
MATZIM LA 420 MG TABLET   2* Tier 2 $0.00$0.00None
MAVYRET 100-40 MG TABLET   5 Tier 5 27%N/AP
MECLIZINE 12.5 MG TABLET [Antivert]   2* Tier 2 $0.00$0.00None
MECLIZINE 25 MG TABLET   2* Tier 2 $0.00$0.00None
MECLOFENAMATE 100MG CAPSULE   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MECLOFENAMATE 50MG CAPSULE   4 Tier 4 $100.00$300.00None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   2* Tier 2 $0.00$0.00None
MEDROXYPROGESTERONE 150 MG/ML SYRINGE [Depo-Provera]   4 Tier 4 $100.00$300.00None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   4 Tier 4 $100.00$300.00None
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   2* Tier 2 $0.00$0.00None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   2* Tier 2 $0.00$0.00None
MEFLOQUINE HCL 250 MG TABLET   3 Tier 3 $47.00$141.00None
MEGESTROL 20 MG TABLET   3 Tier 3 $47.00$141.00P
MEGESTROL 40 MG TABLET   3 Tier 3 $47.00$141.00P
MEGESTROL 625 MG/5 ML ORAL SUSPENSION [Megace ES]   4 Tier 4 $100.00$300.00P
MEGESTROL ACET 40 MG/ML SUSP   3 Tier 3 $47.00$141.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEKINIST 0.5 MG TABLET   5 Tier 5 27%N/AP
MEKINIST 2 MG TABLET   5 Tier 5 27%N/AP
MEKTOVI 15 MG TABLET   5 Tier 5 27%N/AP
MELODETTA 24 FE CHEWABLE TABLET [Minastrin]   2* Tier 2 $0.00$0.00None
MELOXICAM 15 MG TABLET   1* Tier 1 $0.00$0.00None
MELOXICAM 7.5 MG TABLET   1* Tier 1 $0.00$0.00None
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   3 Tier 3 $47.00$141.00P Q:98
/365Days
MEMANTINE HCL 10 MG TABLET [Namenda]   3 Tier 3 $47.00$141.00P Q:60
/30Days
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   3 Tier 3 $47.00$141.00P Q:360
/30Days
MEMANTINE HCL 5 MG TABLET [Namenda]   3 Tier 3 $47.00$141.00P Q:60
/30Days
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR]   4 Tier 4 $100.00$300.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda XR]   4 Tier 4 $100.00$300.00P
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda XR]   4 Tier 4 $100.00$300.00P
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR]   4 Tier 4 $100.00$300.00P
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 Tier 3 $47.00$141.00None
MENVEO A-C-Y-W-135-DIP VIAL   3 Tier 3 $47.00$141.00None
MEPROBAMATE 200 MG TABLET   4 Tier 4 $100.00$300.00P
MEPROBAMATE 400 MG TABLET   4 Tier 4 $100.00$300.00P
MERCAPTOPURINE 50 MG TABLET   4 Tier 4 $100.00$300.00None
MEROPENEM IV 1 GM VIAL [Merrem]   4 Tier 4 $100.00$300.00None
MEROPENEM IV 500 MG VIAL [Merrem]   4 Tier 4 $100.00$300.00None
MESALAMINE 1,000 MG SUPP.RECT [Canasa]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESALAMINE 4 GM/60 ML ENEMA   4 Tier 4 $100.00$300.00Q:1680
/28Days
MESALAMINE 800 MG DR TABLET DR [Asacol HD]   4 Tier 4 $100.00$300.00None
MESALAMINE DR 1.2 GM TABLET   4 Tier 4 $100.00$300.00None
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol]   4 Tier 4 $100.00$300.00None
MESNEX 400MG TABLET   5 Tier 5 27%N/ANone
Metadate er 20 mg tablet   4 Tier 4 $100.00$300.00Q:90
/30Days
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   2* Tier 2 $0.00$0.00None
METFORMIN ER 500 MG GASTRC-TB TABERGR24H [Glumetza]   4 Tier 4 $100.00$300.00P Q:150
/30Days
METFORMIN HCL 1,000 MG TABLET   1* Tier 1 $0.00$0.00None
METFORMIN HCL 500 MG TABLET   1* Tier 1 $0.00$0.00None
METFORMIN HCL 850 MG TABLET   1* Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METFORMIN HCL ER 500 MG OSM-TABLET   4 Tier 4 $100.00$300.00P Q:150
/30Days
METFORMIN HCL ER 500 MG TABLET ER 24H [Prozac]   1* Tier 1 $0.00$0.00None
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR]   1* Tier 1 $0.00$0.00None
METHADONE 10 MG/5 ML SOLUTION   3 Tier 3 $47.00$141.00P Q:3000
/30Days
METHADONE 5 MG/5 ML SOLUTION   3 Tier 3 $47.00$141.00P Q:3000
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   3 Tier 3 $47.00$141.00P Q:180
/30Days
METHADONE HCL 5 MG TABLET [Methadose]   3 Tier 3 $47.00$141.00P Q:180
/30Days
METHAZOLAMIDE 25 MG TABLET [Neptazane]   4 Tier 4 $100.00$300.00None
METHAZOLAMIDE 50 MG TABLET [Neptazane]   4 Tier 4 $100.00$300.00None
METHENAMINE HIPP 1 GM TABLET [Urex]   4 Tier 4 $100.00$300.00None
METHIMAZOLE 10 MG TABLET [Tapazole]   2* Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHIMAZOLE 5 MG TABLET [Tapazole]   2* Tier 2 $0.00$0.00None
METHOTREXATE 2.5 MG TABLET [Rheumatrex]   1* Tier 1 $0.00$0.00None
METHOTREXATE 50 MG/2 ML VIAL   3 Tier 3 $47.00$141.00None
METHOTREXATE 50 MG/2 ML VIAL   3 Tier 3 $47.00$141.00None
Methoxsalen 10 mg Capsule [8-MOP]   5 Tier 5 27%N/ANone
METHSCOPOLAMINE BROM 2.5 MG TABLET [Pamine]   4 Tier 4 $100.00$300.00P
METHSCOPOLAMINE BROM 5 MG TABLET [Pamine Forte]   4 Tier 4 $100.00$300.00P
METHYLDOPA 250 MG TABLET   4 Tier 4 $100.00$300.00P
METHYLDOPA 500 MG TABLET   4 Tier 4 $100.00$300.00P
METHYLPHENIDATE 10 MG CHEW TABLET [Methylin]   4 Tier 4 $100.00$300.00Q:180
/30Days
METHYLPHENIDATE 10 MG TABLET [Ritalin]   3 Tier 3 $47.00$141.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin]   4 Tier 4 $100.00$300.00Q:900
/30Days
METHYLPHENIDATE 2.5 MG CHEW TABLET [Methylin]   4 Tier 4 $100.00$300.00Q:180
/30Days
METHYLPHENIDATE 20 MG TABLET [Ritalin]   3 Tier 3 $47.00$141.00Q:90
/30Days
METHYLPHENIDATE 5 MG CHEW TABLET [Methylin]   4 Tier 4 $100.00$300.00Q:180
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   3 Tier 3 $47.00$141.00Q:90
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin]   4 Tier 4 $100.00$300.00Q:1800
/30Days
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Tier 4 $100.00$300.00Q:90
/30Days
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Tier 4 $100.00$300.00Q:90
/30Days
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 36 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 36 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER 72 MG TABLET ER 24 [RELEXXII]   4 Tier 4 $100.00$300.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE ER(CD) 30MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER(LA) 10MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE ER(LA) 40MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPHENIDATE LA 30 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:60
/30Days
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Tier 4 $100.00$300.00Q:30
/30Days
METHYLPREDNISOLONE 16 MG TABLET [Medrol Dosepak]   2* Tier 2 $0.00$0.00None
METHYLPREDNISOLONE 32 MG TABLET [Medrol]   2* Tier 2 $0.00$0.00None
METHYLPREDNISOLONE 4 MG DOSEPK   2* Tier 2 $0.00$0.00None
METHYLPREDNISOLONE 4 MG TABLET   2* Tier 2 $0.00$0.00None
METHYLPREDNISOLONE 8 MG TABLET [Medrol]   2* Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metoclopramide 10mg/1 500 TABLET BOTTLE   1* Tier 1 $0.00$0.00None
METOCLOPRAMIDE 5 MG TABLET   1* Tier 1 $0.00$0.00None
METOCLOPRAMIDE 5 MG/5 ML SOLUTION   4 Tier 4 $100.00$300.00None
METOCLOPRAMIDE HCL 10 MG ODT   1* Tier 1 $0.00$0.00None
METOCLOPRAMIDE HCL 5 MG ODT   1* Tier 1 $0.00$0.00None
METOLAZONE 10MG TABLET   4 Tier 4 $100.00$300.00None
METOLAZONE 2.5MG TABLET   4 Tier 4 $100.00$300.00None
METOLAZONE 5MG TABLET   4 Tier 4 $100.00$300.00None
METOPROLOL SUCC ER 100 MG TABLET ER 24H [Toprol XL]   2* Tier 2 $0.00$0.00None
METOPROLOL SUCC ER 200 MG TABLET 24H [Toprol XL]   2* Tier 2 $0.00$0.00None
METOPROLOL SUCC ER 25 MG TABLET 24H [Toprol XL]   2* Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL SUCC ER 50 MG TAB   2* Tier 2 $0.00$0.00None
METOPROLOL TARTRATE 100 MG TABLET [Lopressor]   1* Tier 1 $0.00$0.00None
METOPROLOL TARTRATE 25 MG TABLET   1* Tier 1 $0.00$0.00None
METOPROLOL TARTRATE 37.5 MG TABLET   1* Tier 1 $0.00$0.00None
METOPROLOL TARTRATE 75 MG TABLET   1* Tier 1 $0.00$0.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1* Tier 1 $0.00$0.00None
METOPROLOL-HCTZ 100-25 MG TABLET [Lopressor HCT]   3 Tier 3 $47.00$141.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   3 Tier 3 $47.00$141.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   3 Tier 3 $47.00$141.00None
METRONIDAZOLE 0.75% CREAM (g) [Vitazol]   4 Tier 4 $100.00$300.00Q:45
/30Days
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 250 MG TABLET [Flagyl]   3 Tier 3 $47.00$141.00None
METRONIDAZOLE 375 MG CAPSULE [Flagyl]   3 Tier 3 $47.00$141.00None
METRONIDAZOLE 500 MG TABLET [Flagyl]   3 Tier 3 $47.00$141.00None
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   4 Tier 4 $100.00$300.00None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Tier 4 $100.00$300.00None
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   4 Tier 4 $100.00$300.00None
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   4 Tier 4 $100.00$300.00None
MIBELAS 24 FE CHEWABLE TABLET [Minastrin]   2* Tier 2 $0.00$0.00None
MICONAZOLE 3 200MG SUPPOS.   4 Tier 4 $100.00$300.00None
MICROGESTIN 21 1-20 TABLET   3 Tier 3 $47.00$141.00None
MICROGESTIN 21 1.5-30 TABLET   3 Tier 3 $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MICROGESTIN FE 1-20 TABLET [Tarina Fe 1/20]   3 Tier 3 $47.00$141.00None
MICROGESTIN FE 1.5-30 TABLET   3 Tier 3 $47.00$141.00None
MIDODRINE HCL 10 MG TABLET   4 Tier 4 $100.00$300.00None
MIDODRINE HCL 2.5 MG TABLET [ProAmatine]   4 Tier 4 $100.00$300.00None
MIDODRINE HCL 5 MG TABLET [ProAmatine]   4 Tier 4 $100.00$300.00None
MIGLITOL 100 MG TABLET [Glyset]   4 Tier 4 $100.00$300.00Q:90
/30Days
MIGLITOL 25 MG TABLET [Glyset]   4 Tier 4 $100.00$300.00Q:90
/30Days
MIGLITOL 50 MG TABLET [Glyset]   4 Tier 4 $100.00$300.00Q:90
/30Days
MIGLUSTAT 100 MG CAPSULE [Zavesca]   5 Tier 5 27%N/AP
MILI 0.25-0.035 MG TABLET [VyLibra]   2* Tier 2 $0.00$0.00None
MIMVEY 1-0.5 MG TABLET   3 Tier 3 $47.00$141.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINITRAN 0.1 MG/HR PATCH   2* Tier 2 $0.00$0.00None
MINITRAN 0.2 MG/HR PATCH   2* Tier 2 $0.00$0.00None
MINITRAN 0.4 MG/HR PATCH   2* Tier 2 $0.00$0.00None
MINITRAN 0.6 MG/HR PATCH   2* Tier 2 $0.00$0.00None
MINOCYCLINE 100 MG CAPSULE   2* Tier 2 $0.00$0.00None
MINOCYCLINE 50 MG CAPSULE   2* Tier 2 $0.00$0.00None
MINOCYCLINE 75 MG CAPSULE   2* Tier 2 $0.00$0.00None
MINOCYCLINE ER 105 MG TABLET 24H [Solodyn]   4 Tier 4 $100.00$300.00S
MINOCYCLINE ER 115 MG TABLET 24H [Solodyn]   4 Tier 4 $100.00$300.00S
MINOCYCLINE ER 45 MG TABLET 24H [Solodyn]   4 Tier 4 $100.00$300.00S
MINOCYCLINE ER 55 MG TABLET 24H [Solodyn]   4 Tier 4 $100.00$300.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE ER 65 MG TABLET   4 Tier 4 $100.00$300.00S
MINOCYCLINE ER 80 MG TABLET 24H [Solodyn]   4 Tier 4 $100.00$300.00S
MINOCYCLINE HCL 100 MG TABLET   4 Tier 4 $100.00$300.00S
MINOCYCLINE HCL 75 MG TABLET   4 Tier 4 $100.00$300.00S
MINOCYCLINE HYDROCHLORIDE 50 MG TABLET   4 Tier 4 $100.00$300.00S
MINOCYCLINE HYDROCHLORIDE TABLETS ER 135MG   4 Tier 4 $100.00$300.00S
MINOCYCLINE HYDROCHLORIDE TABLETS ER 90MG   4 Tier 4 $100.00$300.00S
MINOXIDIL 10MG TABLET   2* Tier 2 $0.00$0.00None
MINOXIDIL 2.5MG TABLET   2* Tier 2 $0.00$0.00None
MIRTAZAPINE 15 MG ODT   3 Tier 3 $47.00$141.00Q:30
/30Days
MIRTAZAPINE 15 MG TABLET [Remeron]   2* Tier 2 $0.00$0.00Q:30
/30Days
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$141.00Q:30
/30Days
MIRTAZAPINE 30 MG TABLET [Remeron]   2* Tier 2 $0.00$0.00Q:30
/30Days
MIRTAZAPINE 45 MG ODT   3 Tier 3 $47.00$141.00Q:30
/30Days
MIRTAZAPINE 45 MG TABLET   2* Tier 2 $0.00$0.00Q:30
/30Days
MIRTAZAPINE 7.5 MG TABLET   2* Tier 2 $0.00$0.00Q:30
/30Days
MISOPROSTOL 100 MCG TABLET [Cytotec]   3 Tier 3 $47.00$141.00None
MISOPROSTOL 200 MCG TABLET [Cytotec]   3 Tier 3 $47.00$141.00None
MITIGARE 0.6 MG CAPSULE   3 Tier 3 $47.00$141.00Q:60
/30Days
MODAFINIL 100 MG TABLET [Provigil]   3 Tier 3 $47.00$141.00P Q:30
/30Days
MODAFINIL 200 MG TABLET [Provigil]   3 Tier 3 $47.00$141.00P Q:60
/30Days
MOEXIPRIL HCL 15 MG TABLET [Univasc]   1* Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOEXIPRIL HCL 7.5 MG TABLET   1* Tier 1 $0.00$0.00None
MOLINDONE HCL 10 MG TABLET   3 Tier 3 $47.00$141.00None
MOLINDONE HCL 25 MG TABLET   3 Tier 3 $47.00$141.00None
MOLINDONE HCL 5 MG TABLET   3 Tier 3 $47.00$141.00None
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon]   3 Tier 3 $47.00$141.00None
MOMETASONE FUROATE 0.1% OINTMENT   3 Tier 3 $47.00$141.00None
MOMETASONE FUROATE 0.1% SOLUTION   3 Tier 3 $47.00$141.00None
MOMETASONE FUROATE 50 MCG SPRAY   3 Tier 3 $47.00$141.00Q:34
/30Days
MONDOXYNE NL 100 MG CAPSULE [Monodox]   4 Tier 4 $100.00$300.00None
MONDOXYNE NL 75 MG CAPSULE [NutriDox]   4 Tier 4 $100.00$300.00None
MONTELUKAST SOD 10 MG TABLET [Singulair]   2* Tier 2 $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MONTELUKAST SOD 4 MG CHEWABLE TABLET [Singulair]   2* Tier 2 $0.00$0.00Q:30
/30Days
MONTELUKAST SOD 4 MG GRANULES [Singulair]   3 Tier 3 $47.00$141.00Q:30
/30Days
MONTELUKAST SOD 5 MG CHEWABLE TABLET [Singulair]   2* Tier 2 $0.00$0.00Q:30
/30Days
MORPHINE SULF 10 MG/5 ML Solution [MSIR]   3 Tier 3 $47.00$141.00Q:1800
/30Days
MORPHINE SULF 20 MG/5 ML SOLUTION [MSIR]   3 Tier 3 $47.00$141.00Q:900
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Tier 3 $47.00$141.00P Q:60
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Tier 3 $47.00$141.00P Q:90
/30Days
MORPHINE SULF ER 200 MG TABLET   3 Tier 3 $47.00$141.00P Q:60
/30Days
MORPHINE SULF ER 30 MG TABLET   3 Tier 3 $47.00$141.00P Q:60
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Tier 3 $47.00$141.00P Q:60
/30Days
MORPHINE SULFATE 100 MG/5 ML SOLUTION   4 Tier 4 $100.00$300.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE ER 10 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 100 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 120 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
MORPHINE SULFATE ER 20 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 30 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
MORPHINE SULFATE ER 30 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 40 MG CAPSULE PEL [Kadian]   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 45 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
MORPHINE SULFATE ER 50 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 60 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
MORPHINE SULFATE ER 60 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE ER 75 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
MORPHINE SULFATE ER 80 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
MORPHINE SULFATE ER 90 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
MORPHINE SULFATE IR 15 MG TABLET [MSIR]   3 Tier 3 $47.00$141.00Q:180
/30Days
MORPHINE SULFATE IR 30 MG TABLET [MSIR]   3 Tier 3 $47.00$141.00Q:180
/30Days
MOVANTIK 12.5 MG TABLET   3 Tier 3 $47.00$141.00Q:60
/30Days
MOVANTIK 25 MG TABLET   3 Tier 3 $47.00$141.00Q:30
/30Days
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   3 Tier 3 $47.00$141.00None
MOXIFLOXACIN 0.5% EYE DROPS [Vigamox]   3 Tier 3 $47.00$141.00None
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.]   4 Tier 4 $100.00$300.00None
MOXIFLOXACIN HCL 400 MG TABLET [Avelox ABC Pack]   4 Tier 4 $100.00$300.00None
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   4 Tier 4 $100.00$300.00None
MUPIROCIN 2% CREAM (g) [Bactroban]   4 Tier 4 $100.00$300.00Q:30
/30Days
MUPIROCIN 2% OINTMENT [Centany AT]   2* Tier 2 $0.00$0.00Q:30
/30Days
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION   5 Tier 5 27%N/ANone
MYCAMINE 50MG VIAL   4 Tier 4 $100.00$300.00None
MYCOPHENOLATE 200 MG/ML SUSP   5 Tier 5 27%N/AP
MYCOPHENOLATE 250 MG CAPSULE [CellCept]   3 Tier 3 $47.00$141.00P
MYCOPHENOLATE 500 MG TABLET [CellCept]   3 Tier 3 $47.00$141.00P
MYCOPHENOLIC ACID DR 180 MG TABLET   4 Tier 4 $100.00$300.00P
MYCOPHENOLIC ACID DR 360 MG TABLET   4 Tier 4 $100.00$300.00P
MYORISAN 10 MG CAPSULE   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MYORISAN 20 MG CAPSULE   4 Tier 4 $100.00$300.00None
Myorisan 30 mg capsule   4 Tier 4 $100.00$300.00None
MYORISAN 40 MG CAPSULE   4 Tier 4 $100.00$300.00None
MYRBETRIQ ER 25 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days
MYRBETRIQ ER 50 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Aetna Medicare Premier (PPO) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $435 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).

  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.


(Chart Source: Centers for Medicare and Medicaid files: CMS Data May 2020 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.






 
 

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.