2024 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Essential (PDP) (S7126-107-0)
Benefits & Contact Info
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Mutual of Omaha Rx Essential (PDP) (S7126-107-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 5 which includes: DC DE MD
|
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 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MAGNESIUM SULFATE 50% SYRINGE |
4 |
Non-Preferred Drug |
48% | N/A | None |
MAGNESIUM SULFATE 50% VIAL |
4 |
Non-Preferred Drug |
48% | N/A | None |
MALATHION 0.5% LOTION |
4 |
Non-Preferred Drug |
48% | N/A | None |
MARAVIROC 150 MG TABLET [Selzentry] |
5 |
Specialty Tier |
25% | N/A | None |
MARAVIROC 300 MG TABLET [Selzentry] |
5 |
Specialty Tier |
25% | N/A | None |
MARLISSA-28 TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
48% | N/A | None |
MATULANE 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
MATZIM LA 180 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 [Antivert] |
2 |
Generic |
$15.00 | $37.50 | None |
MECLIZINE 25 MG TABLET [Meni-D] |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROXYPROGESTERONE 10 MG TABLET [Provera] |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROXYPROGESTERONE 150 MG/ML SYRINGE [Depo-Provera] |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera] |
2 |
Generic |
$15.00 | $37.50 | None |
MEDROXYPROGESTERONE 5 MG TABLET [Provera] |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEFLOQUINE HCL 250 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MEGESTROL 20 MG TABLET [Megace] |
3 |
Preferred Brand |
20% | 20% | P |
MEGESTROL 40 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P |
MEGESTROL 625 MG/5 ML ORAL SUSPENSION [Megace ES] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MEGESTROL ACET 40 MG/ML ORAL SUSPENSION [Megace] |
3 |
Preferred Brand |
20% | 20% | P |
MEKINIST 0.05 MG/ML SOLUTION RECON |
5 |
Specialty Tier |
25% | N/A | P Q:1200 /30Days |
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 |
MELOXICAM 15 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
MELOXICAM 7.5 MG TABLET [Mobic] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEMANTINE HCL 10 MG TABLET [Namenda] |
3 |
Preferred Brand |
20% | 20% | P |
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MEMANTINE HCL 5 MG TABLET [Namenda] |
3 |
Preferred Brand |
20% | 20% | P |
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda XR] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda XR] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR] |
4 |
Non-Preferred Drug |
48% | N/A | 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 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MENEST 0.3MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MENEST 0.625MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MENEST 1.25MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 2.5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MENQUADFI VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MENVEO A-C-Y-W-135-DIP VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MERCAPTOPURINE 50 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
MEROPENEM IV 1 GM VIAL [Merrem] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:30 /10Days |
MEROPENEM IV 500 MG VIAL [Merrem] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:10 /10Days |
MESALAMINE 1,000 MG SUPP.RECT [Canasa] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MESALAMINE 4 GM/60 ML ENEMA |
4 |
Non-Preferred Drug |
48% | N/A | None |
MESALAMINE 800 MG DR TABLET DR [Asacol HD] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MESALAMINE DR 1.2 GM TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESALAMINE ER 0.375 GRAM CAPSULE ER 24H [Apriso] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MESALAMINE ER 500 MG CAPSULE ER [Pentasa] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MESNEX 400MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
METFORMIN HCL 1,000 MG TABLET [Glucophage] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:75 /30Days |
METFORMIN HCL 500 MG TABLET [Glucophage] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:150 /30Days |
METFORMIN HCL 850 MG TABLET [Glucophage] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
METFORMIN HCL ER 500 MG TABLET 24H [Glumetza] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
METFORMIN HCL ER 750 MG TABLET 24H [Glucophage XR] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
METHADONE 10 MG/5 ML SOLUTION |
3 |
Preferred Brand |
20% | 20% | P Q:600 /30Days |
METHADONE 5 MG/5 ML SOLUTION |
3 |
Preferred Brand |
20% | 20% | P Q:1200 /30Days |
METHADONE HCL 10 MG TABLET [Methadose] |
3 |
Preferred Brand |
20% | 20% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HCL 5 MG TABLET [Methadose] |
3 |
Preferred Brand |
20% | 20% | P Q:240 /30Days |
METHAZOLAMIDE 25 MG TABLET [Neptazane] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHAZOLAMIDE 50 MG TABLET [Neptazane] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHENAMINE HIPP 1 GM TABLET [Urex] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHIMAZOLE 10 MG TABLET [Tapazole] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METHIMAZOLE 5 MG TABLET [Tapazole] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METHOCARBAMOL 500 MG TABLET [Robaxin] |
3 |
Preferred Brand |
20% | 20% | None |
METHOCARBAMOL 750 MG TABLET [Robaxin] |
3 |
Preferred Brand |
20% | 20% | None |
METHOTREXATE 2.5 MG TABLET [Rheumatrex] |
2 |
Generic |
$15.00 | $37.50 | P |
METHOTREXATE 50 MG/2 ML VIAL |
3 |
Preferred Brand |
20% | 20% | P |
METHOTREXATE 50 MG/2 ML VIAL |
3 |
Preferred Brand |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methoxsalen 10 mg Capsule [8-MOP] |
5 |
Specialty Tier |
25% | N/A | None |
METHSUXIMIDE 300 MG CAPSULE [Celontin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE 10 MG CHEWABLE TABLET [Methylin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE 10 MG TABLET [Ritalin] |
3 |
Preferred Brand |
20% | 20% | None |
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE 2.5 MG CHEWABLE TABLET [Methylin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE 20 MG TABLET [Ritalin] |
3 |
Preferred Brand |
20% | 20% | None |
METHYLPHENIDATE 5 MG CHEWABLE TABLET [Methylin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE 5 MG TABLET [Ritalin] |
3 |
Preferred Brand |
20% | 20% | None |
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE ER 10 MG TABLET [Methylin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE LA 10 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE LA 30 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 [Ritalin LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METHYLPREDNISOLONE 16 MG TABLET [Medrol Dosepak] |
2 |
Generic |
$15.00 | $37.50 | P |
METHYLPREDNISOLONE 32 MG TABLET [Medrol] |
2 |
Generic |
$15.00 | $37.50 | P |
METHYLPREDNISOLONE 4 MG DOSEPK |
2 |
Generic |
$15.00 | $37.50 | None |
METHYLPREDNISOLONE 4 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | P |
METHYLPREDNISOLONE 8 MG TABLET [Medrol] |
2 |
Generic |
$15.00 | $37.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $37.50 | None |
METOCLOPRAMIDE 5 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METOCLOPRAMIDE 5 MG/5 ML SOLUTION |
2 |
Generic |
$15.00 | $37.50 | None |
METOLAZONE 10 MG TABLET [Zaroxolyn] |
3 |
Preferred Brand |
20% | 20% | None |
METOLAZONE 2.5 MG TABLET [Zaroxolyn] |
3 |
Preferred Brand |
20% | 20% | None |
METOLAZONE 5 MG TABLET [Zaroxolyn] |
3 |
Preferred Brand |
20% | 20% | None |
METOPROLOL SUCC ER 100 MG TABLET 24H [Toprol XL] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 200 MG TABLET ER 24H [Toprol XL] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 25 MG TABLET 24H [Toprol XL] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL SUCC ER 50 MG TABLET ER 24H [Toprol XL] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 100 MG TABLET [Lopressor] |
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 TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 37.5 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METOPROLOL TARTRATE 50 MG TABLET [Lopressor] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE 75 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METOPROLOL-HCTZ 100-25 MG TABLET [Lopressor HCT] |
2 |
Generic |
$15.00 | $37.50 | None |
METOPROLOL-HCTZ 50-25 MG TABLET [Lopressor HCT] |
2 |
Generic |
$15.00 | $37.50 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
METRONIDAZOLE 0.75% CREAM (G) [Vitazol] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METRONIDAZOLE 0.75% LOTION [MetroLotion] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METRONIDAZOLE 250 MG TABLET [Flagyl] |
2 |
Generic |
$15.00 | $37.50 | None |
METRONIDAZOLE 500 MG TABLET [Flagyl] |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU] |
4 |
Non-Preferred Drug |
48% | N/A | P |
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METRONIDAZOLE TOPICAL 1% GEL [MetroGel] |
4 |
Non-Preferred Drug |
48% | N/A | None |
METRONIDAZOLE VAGINAL 0.75% GEL W/APPL [Vandazole] |
3 |
Preferred Brand |
20% | 20% | None |
METYROSINE 250 MG CAPSULE [Demser] |
5 |
Specialty Tier |
25% | N/A | P |
MICAFUNGIN 100 MG VIAL [Mycamine] |
5 |
Specialty Tier |
25% | N/A | None |
MICAFUNGIN 50 MG VIAL [Mycamine] |
5 |
Specialty Tier |
25% | N/A | None |
MICROGESTIN 21 1-20 TABLET [Microgestin 1/20] |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN 21 1.5-30 TABLET [Microgestin 1.5/30] |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN FE 1-20 TABLET [Tarina Fe 1/20] |
2 |
Generic |
$15.00 | $37.50 | None |
MICROGESTIN FE 1.5-30 TABLET [Microgestin Fe 1.5/30] |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIDODRINE HCL 10 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MIDODRINE HCL 2.5 MG TABLET [ProAmatine] |
3 |
Preferred Brand |
20% | 20% | None |
MIDODRINE HCL 5 MG TABLET [ProAmatine] |
3 |
Preferred Brand |
20% | 20% | None |
MIFEPRISTONE 300 MG TABLET [Korlym] |
5 |
Specialty Tier |
25% | N/A | P |
MILI 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
$15.00 | $37.50 | None |
MIMVEY 1-0.5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MINOCYCLINE 100 MG CAPSULE |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE 50 MG CAPSULE [Minocin PAC] |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE 75 MG CAPSULE [Minocin] |
2 |
Generic |
$15.00 | $37.50 | None |
MINOCYCLINE HCL 100 MG TABLET [Myrac] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MINOCYCLINE HCL 50 MG TABLET [Myrac] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE HCL 75 MG TABLET [Myrac] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MINOXIDIL 10 MG TABLET [Loniten] |
2 |
Generic |
$15.00 | $37.50 | None |
MINOXIDIL 2.5 MG TABLET [Loniten] |
2 |
Generic |
$15.00 | $37.50 | None |
MIRABEGRON ER 25 MG TABLET 24H [Myrbetriq] |
3 |
Preferred Brand |
20% | 20% | None |
MIRABEGRON ER 50 MG TABLET 24H [Myrbetriq] |
3 |
Preferred Brand |
20% | 20% | None |
MIRTAZAPINE 15 MG ODT |
3 |
Preferred Brand |
20% | 20% | None |
MIRTAZAPINE 15 MG TABLET [Remeron] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE 30 MG ODT TABLET RAPDIS [Remeron SolTab] |
3 |
Preferred Brand |
20% | 20% | None |
MIRTAZAPINE 30 MG TABLET [Remeron] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MIRTAZAPINE 45 MG ODT |
3 |
Preferred Brand |
20% | 20% | None |
MIRTAZAPINE 45 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 |
MIRTAZAPINE 7.5 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
MISOPROSTOL 100 MCG TABLET [Cytotec] |
3 |
Preferred Brand |
20% | 20% | None |
MISOPROSTOL 200 MCG TABLET [Cytotec] |
3 |
Preferred Brand |
20% | 20% | None |
MODAFINIL 100 MG TABLET [Provigil] |
3 |
Preferred Brand |
20% | 20% | P Q:30 /30Days |
MODAFINIL 200 MG TABLET [Provigil] |
3 |
Preferred Brand |
20% | 20% | P Q:60 /30Days |
MOEXIPRIL HCL 15 MG TABLET [Univasc] |
3 |
Preferred Brand |
20% | 20% | None |
MOEXIPRIL HCL 7.5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MOLINDONE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
MOLINDONE HCL 25 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
MOLINDONE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
MOMETASONE FUROATE 0.1% CREAM (G) [Elocon] |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOMETASONE FUROATE 0.1% OINTMENT [Elocon] |
2 |
Generic |
$15.00 | $37.50 | None |
MOMETASONE FUROATE 0.1% SOLUTION |
2 |
Generic |
$15.00 | $37.50 | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MONTELUKAST SOD 4 MG CHEWABLE TABLET [Singulair] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MONTELUKAST SOD 4 MG GRANULES [Singulair] |
4 |
Non-Preferred Drug |
48% | N/A | None |
MONTELUKAST SOD 5 MG CHEWABLE TABLET [Singulair] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
MORPHINE SULF 10 MG/5 ML SOLUTION [MSIR] |
3 |
Preferred Brand |
20% | 20% | Q:900 /30Days |
MORPHINE SULF 100 MG/5 ML CONC SOLUTION [Roxanol-T] |
3 |
Preferred Brand |
20% | 20% | Q:900 /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% | P Q:120 /30Days |
MORPHINE SULF ER 15 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULF ER 200 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P Q:120 /30Days |
MORPHINE SULF ER 30 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P Q:120 /30Days |
MORPHINE SULF ER 60 MG TABLET |
3 |
Preferred Brand |
20% | 20% | P Q:120 /30Days |
MORPHINE SULFATE IR 15 MG TABLET [MSIR] |
3 |
Preferred Brand |
20% | 20% | Q:180 /30Days |
MORPHINE SULFATE IR 30 MG TABLET [MSIR] |
3 |
Preferred Brand |
20% | 20% | Q:180 /30Days |
MOUNJARO 10 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
MOUNJARO 12.5 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
MOUNJARO 15 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
MOUNJARO 2.5 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
MOUNJARO 5 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
MOUNJARO 7.5 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOVANTIK 12.5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
MOVANTIK 25 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
MOXIFLOXACIN 0.5% EYE DROPS [Vigamox] |
3 |
Preferred Brand |
20% | 20% | None |
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox ABC Pack] |
3 |
Preferred Brand |
20% | 20% | None |
MULTIPLE ELECTROLYTES T1 PH5.5 IV SOLUTION |
3 |
Preferred Brand |
20% | 20% | None |
MUPIROCIN 2% OINTMENT [Centany AT] |
2 |
Generic |
$15.00 | $37.50 | Q:44 /30Days |
MYALEPT 11.3 MG (5 MG/ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
MYCOPHENOLATE 200 MG/ML SUSP |
5 |
Specialty Tier |
25% | N/A | P |
MYCOPHENOLATE 250 MG CAPSULE [CellCept] |
3 |
Preferred Brand |
20% | 20% | P |
MYCOPHENOLATE 500 MG TABLET [CellCept] |
3 |
Preferred Brand |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLIC ACID DR 180 MG TABLET DR [Myfortic] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MYCOPHENOLIC ACID DR 360 MG TABLET DR [Myfortic] |
4 |
Non-Preferred Drug |
48% | N/A | P |
MYFEMBREE 40 MG-1 MG-0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
MYRBETRIQ ER 25 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MYRBETRIQ ER 50 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
MYRBETRIQ ER 8 MG/ML SUSP ER REC |
3 |
Preferred Brand |
20% | 20% | None |