2021 Medicare Part D Plan Formulary Information |
Triple S Platino Enlace (HMO D-SNP) (H5774-032-0)
Benefit Details
|
The Triple S Platino Enlace (HMO D-SNP) (H5774-032-0) Formulary Drugs Starting with the Letter M in Adjuntas County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $445 |
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 |
$42.00 | $84.00 | None |
MAGNESIUM SULFATE 50% VIAL |
1 |
Preferred Generic |
$14.00 | $28.00 | P |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
MATULANE 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
MAVYRET 100-40 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
MAYZENT 0.25 MG STARTER PACK TABLET DS PK |
5 |
Specialty Tier |
25% | 25% | P |
MAYZENT 0.25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
MAYZENT 2 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
MECLIZINE 12.5 MG TABLET [Antivert] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MECLIZINE 25 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | 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 |
$14.00 | $28.00 | None |
MEDROXYPROGESTERONE 150 MG/ML SYRINGE [Depo-Provera] |
2 |
Generic |
$15.00 | $30.00 | Q:1 /90Days |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
2 |
Generic |
$15.00 | $30.00 | Q:1 /90Days |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MEFLOQUINE HCL 250 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
MEGESTROL 20 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P |
MEGESTROL 40 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P |
MEGESTROL ACET 40 MG/ML ORAL SUSPENSION [Megace] |
2 |
Generic |
$15.00 | $30.00 | P |
MEKINIST 0.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
MEKINIST 2 MG TABLET |
5 |
Specialty Tier |
25% | 25% | 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% | 25% | P |
MELOXICAM 15 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MELOXICAM 7.5 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration] |
2 |
Generic |
$15.00 | $30.00 | P |
MEMANTINE HCL 10 MG TABLET [Namenda] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
2 |
Generic |
$15.00 | $30.00 | P |
MEMANTINE HCL 5 MG TABLET [Namenda] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Generic |
$15.00 | $30.00 | P |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Generic |
$15.00 | $30.00 | P |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Generic |
$15.00 | $30.00 | P |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR] |
2 |
Generic |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$42.00 | $84.00 | None |
MENVEO A-C-Y-W-135-DIP VIAL |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
MEPERIDINE 50 MG/ML VIAL [Demerol] |
2 |
Generic |
$15.00 | $30.00 | P |
MERCAPTOPURINE 50 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
MEROPENEM IV 500 MG VIAL [Merrem] |
2 |
Generic |
$15.00 | $30.00 | None |
MESALAMINE 1,000 MG SUPP.RECT [Canasa] |
2 |
Generic |
$15.00 | $30.00 | None |
MESALAMINE 4 GM/60 ML ENEMA |
2 |
Generic |
$15.00 | $30.00 | None |
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol] |
2 |
Generic |
$15.00 | $30.00 | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
METFORMIN HCL 1,000 MG TABLET |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
METFORMIN HCL 500 MG TABLET |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METFORMIN HCL 500 MG/5 ML SOLUTION [Riomet] |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
METFORMIN HCL 850 MG TABLET [Glucophage] |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
METFORMIN HCL ER 500 MG TABLET ER 24H [Prozac] |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR] |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
METHAZOLAMIDE 25 MG TABLET [Neptazane] |
2 |
Generic |
$15.00 | $30.00 | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METHOTREXATE 2.5 MG TABLET [Rheumatrex] |
2 |
Generic |
$15.00 | $30.00 | None |
METHOTREXATE 50 MG/2 ML VIAL |
1 |
Preferred Generic |
$14.00 | $28.00 | P |
METHOTREXATE 50 MG/2 ML VIAL |
2 |
Generic |
$15.00 | $30.00 | P |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROM 2.5 MG TABLET [Pamine] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLDOPA 250 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P |
METHYLDOPA 500 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLPHENIDATE ER(CD) 10MG CAPSULE CPBP 30-70 [Ritalin LA] |
2 |
Generic |
$15.00 | $30.00 | None |
METHYLPREDNISOLONE 16 MG TABLET [Medrol Dosepak] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 32 MG TABLET [Medrol] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METHYLPREDNISOLONE 4 MG DOSEPK |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METHYLPREDNISOLONE 4 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METHYLPREDNISOLONE 8 MG TABLET [Medrol] |
2 |
Generic |
$15.00 | $30.00 | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLUTION |
2 |
Generic |
$15.00 | $30.00 | None |
METOLAZONE 10 MG TABLET [Zaroxolyn] |
2 |
Generic |
$15.00 | $30.00 | None |
METOLAZONE 2.5 MG TABLET [Zaroxolyn] |
2 |
Generic |
$15.00 | $30.00 | None |
METOLAZONE 5 MG TABLET [Zaroxolyn] |
2 |
Generic |
$15.00 | $30.00 | None |
METOPROLOL SUCC ER 100 MG TABLET ER 24H [Toprol XL] |
2 |
Generic |
$15.00 | $30.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL SUCC ER 200 MG TABLET ER 24H [Toprol XL] |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
METOPROLOL SUCC ER 25 MG TABLET ER 24H [Toprol XL] |
1 |
Preferred Generic |
$14.00 | $28.00 | Q:60 /30Days |
METOPROLOL SUCC ER 50 MG TABLET ER 24H [Toprol XL] |
1 |
Preferred Generic |
$14.00 | $28.00 | Q:60 /30Days |
METOPROLOL TARTRATE 100 MG TABLET [Lopressor] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOPROLOL TARTRATE 25 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOPROLOL TARTRATE 37.5 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOPROLOL TARTRATE 50 MG TABLET [Lopressor] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOPROLOL TARTRATE 75 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METOPROLOL-HCTZ 100-25 MG TABLET [Lopressor HCT] |
2 |
Generic |
$15.00 | $30.00 | None |
METOPROLOL-HCTZ 50-25 MG TABLET [Lopressor HCT] |
2 |
Generic |
$15.00 | $30.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
2 |
Generic |
$15.00 | $30.00 | P |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
2 |
Generic |
$15.00 | $30.00 | None |
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole] |
2 |
Generic |
$15.00 | $30.00 | None |
METYROSINE 250 MG CAPSULE [Demser] |
5 |
Specialty Tier |
25% | 25% | None |
MEXILETINE 150MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
MEXILETINE 200MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
MEXILETINE 250MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
MIDODRINE HCL 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
MIDODRINE HCL 2.5 MG TABLET [ProAmatine] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 5 MG TABLET [ProAmatine] |
2 |
Generic |
$15.00 | $30.00 | None |
MIGLUSTAT 100 MG CAPSULE [Zavesca] |
5 |
Specialty Tier |
25% | 25% | P |
MINITRAN 0.1 MG/HR PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
MINITRAN 0.2 MG/HR PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
MINITRAN 0.4 MG/HR PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
MINITRAN 0.6 MG/HR PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
MINOCYCLINE 100 MG CAPSULE |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MINOCYCLINE 50 MG CAPSULE [Minocin PAC] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MINOCYCLINE 75 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
MINOXIDIL 10 MG TABLET [Loniten] |
2 |
Generic |
$15.00 | $30.00 | None |
MINOXIDIL 2.5 MG TABLET [Loniten] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 15 MG ODT |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
MIRTAZAPINE 15 MG TABLET [Remeron] |
1 |
Preferred Generic |
$14.00 | $28.00 | Q:30 /30Days |
MIRTAZAPINE 30 MG ODT |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
MIRTAZAPINE 30 MG TABLET [Remeron] |
1 |
Preferred Generic |
$14.00 | $28.00 | Q:30 /30Days |
MIRTAZAPINE 45 MG ODT |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
MIRTAZAPINE 45 MG TABLET |
1 |
Preferred Generic |
$14.00 | $28.00 | Q:30 /30Days |
MIRTAZAPINE 7.5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
MISOPROSTOL 200 MCG TABLET [Cytotec] |
2 |
Generic |
$15.00 | $30.00 | None |
MODAFINIL 100 MG TABLET [Provigil] |
2 |
Generic |
$15.00 | $30.00 | P |
MODAFINIL 200 MG TABLET [Provigil] |
2 |
Generic |
$15.00 | $30.00 | P |
MOEXIPRIL HCL 15 MG TABLET [Univasc] |
6 |
Select Care Drugs |
$2.00 | $4.00 | 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 |
Select Care Drugs |
$2.00 | $4.00 | None |
MOLINDONE HCL 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
MOLINDONE HCL 25 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
MOLINDONE HCL 5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MOMETASONE FUROATE 0.1% OINTMENT |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MOMETASONE FUROATE 0.1% SOLUTION |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MONTELUKAST SOD 4 MG CHEWABLE TABLET [Singulair] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MONTELUKAST SOD 4 MG GRANULES [Singulair] |
2 |
Generic |
$15.00 | $30.00 | None |
MONTELUKAST SOD 5 MG CHEWABLE TABLET [Singulair] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULF 100 MG/5 ML CONC SOLUTION [Roxanol-T] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
MORPHINE SULF ER 100 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P Q:36 /30Days |
MORPHINE SULF ER 15 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P Q:90 /30Days |
MORPHINE SULF ER 200 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P Q:60 /30Days |
MORPHINE SULF ER 30 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P Q:90 /30Days |
MORPHINE SULF ER 60 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P Q:90 /30Days |
MORPHINE SULFATE IR 15 MG TABLET [MSIR] |
2 |
Generic |
$15.00 | $30.00 | Q:180 /30Days |
MORPHINE SULFATE IR 30 MG TABLET [MSIR] |
2 |
Generic |
$15.00 | $30.00 | Q:180 /30Days |
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.] |
2 |
Generic |
$15.00 | $30.00 | P |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
MUPIROCIN 2% OINTMENT [Centany AT] |
1 |
Preferred Generic |
$14.00 | $28.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCAMINE 100 MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
MYCAMINE 50 MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
MYCOPHENOLATE 200 MG/ML SUSP |
2 |
Generic |
$15.00 | $30.00 | P |
MYCOPHENOLATE 250 MG CAPSULE [CellCept] |
1 |
Preferred Generic |
$14.00 | $28.00 | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
2 |
Generic |
$15.00 | $30.00 | P |
MYCOPHENOLIC ACID DR 180 MG TABLET DR [Myfortic] |
2 |
Generic |
$15.00 | $30.00 | P |
MYCOPHENOLIC ACID DR 360 MG TABLET DR [Myfortic] |
2 |
Generic |
$15.00 | $30.00 | P |
MYRBETRIQ ER 25 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
MYRBETRIQ ER 50 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |