2015 HealthPartners Freedom Ultimate with Rx (Cost) Drug Coverage Details



Below is the Formulary, or drug list, for HealthPartners Freedom Ultimate with Rx (Cost) from Group Health Plan, Inc. (mn) This formulary is a list of prescription medications that are covered under Group Health Plan, Inc. (mn)'s 2015 Medicare Advantage Plan. The HealthPartners Freedom Ultimate with Rx (Cost) plan has a $160 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $2960. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $2960 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2015 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. HealthPartners Freedom Ultimate with Rx (Cost) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.





Plan Name:
HealthPartners Freedom Ultimate with Rx (Cost)
Plan ID:
H2462-011
Provider: Group Health Plan, Inc. (mn)
Plan Year:2015
Premium:$39.70
Deductible:$160
Initial Coverage Limit:$2960
Coverage Area:Minnesota






Current Table info:


Coverage level : Initial Coverage
Days Supply : 30 Days
Drugs Starting With Letter: M



Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M 
N  O  P  Q  R  S  T  U  V  W  X  Y  Z 

Coverage Level:
Pre-deductible,Initial Coverage
Coverage Gap, Catastrophic

Drug Days Pricing:
30 Day Supply, 60 Day Supply, 90 Day Supply

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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization Y/N Step Therapy Y/N Does the Deduct Apply Cost Prefered Max Cost Pref Cost Non Pref Max Cost Non Pref Cost Amt Mail Max Cost Mail
M-m-r Ii 1000; 12500; 1000[TCID_50]/.5mL; [TCID_50]/.5mL; [TCID_50]/.5mL 10 Vial, Single-dose In 1 Carton
3
N N N N Y $45None$45None$45None
Macrodantin 25mg 100 Capsule In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Malathion 5mg/mL 1 Bottle In 1 Carton > 59 Ml In 1 Bottle
2
N N N N Y $15None$15None$15None
Maprotiline Hydrochloride 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Maprotiline Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Maprotiline Hydrochloride 75mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Marlissa 3 Blister Pack In 1 Carton
2
N N N N Y $15None$15None$15None
Marplan 10mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y $95None$95None$95None
Matulane 50mg 100 Capsule In 1 Bottle
5
N N N N N 33%None33%None33%None
Matzim La 180mg 90 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Matzim La 240mg 90 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Matzim La 300mg 90 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Matzim La 360mg 90 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Matzim La 420mg 90 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Meclizine Hydrochloride 25mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Medroxyprogesterone Acetate 10mg 500 Tablet In 1 Bottle
1
N N N N Y $5None$5None$5None
Medroxyprogesterone Acetate 2.5mg 500 Tablet In 1 Bottle
1
N N N N Y $5None$5None$5None
Medroxyprogesterone Acetate 5mg 500 Tablet In 1 Bottle
1
N N N N Y $5None$5None$5None
Mefloquine Hydrochloride 250mg 1 Bottle In 1 Carton > 25 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Megace Es 125mg/mL 150 Ml In 1 Bottle
3
N N N N Y $45None$45None$45None
Megestrol Acetate 20mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Megestrol Acetate 40mg 250 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Megestrol Acetate 40mg/mL 480 Ml In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Mekinist 2mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y N N 33%None33%None33%None
Mekinist .5mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y N N 33%None33%None33%None
Meloxicam 7.5mg/5mL 1 Bottle, Glass In 1 Carton > 100 Ml In 1 Bottle, Glass
1
N N N N Y $5None$5None$5None
Meloxicam 7.5mg 100 Tablet In 1 Bottle
1
N N N N Y $5None$5None$5None
Meloxicam 15mg 100 Tablet In 1 Bottle
1
N N N N Y $5None$5None$5None
Melphalan Hydrochloride 1 Kit In 1 Carton
5
N N Y N N 33%None33%None33%None
Menactra 4; 4; 4; 4ug/.5mL; ug/.5mL; ug/.5mL; ug/.5mL 5 Vial, Single-dose In 1 Package > .5 Ml In 1 Vial, Single-dose
3
N N N N Y $45None$45None$45None
Menest .3mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y N Y $45None$45None$45None
Menest .625mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y N Y $45None$45None$45None
Menest 1.25mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y N Y $45None$45None$45None
Menest 2.5mg 50 Tablet, Film Coated In 1 Bottle
3
N N Y N Y $45None$45None$45None
Menomune - A/c/y/w-135 Combined 1 Kit In 1 Package
3
N N N N Y $45None$45None$45None
Menveo 5 Kit In 1 Carton
3
N N N N Y $45None$45None$45None
Mercaptopurine 50mg 25 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Meropenem 500mg/10mL 25 Vial In 1 Carton > 10 Ml In 1 Vial
2
N N N N Y $15None$15None$15None
Mesalamine 1 Kit In 1 Carton * 1 Swab In 1 Packet
2
N N N N Y $15None$15None$15None
Mesna 100mg/mL 10 Vial, Multi-dose In 1 Tray > 10 Ml In 1 Vial, Multi-dose
2
N N Y N Y $15None$15None$15None
Mesnex 400mg 10 Blister Pack In 1 Carton > 1 Tablet, Film Coated In 1 Blister Pack
5
N N N N N 33%None33%None33%None
Mestinon 60mg/5mL 473 Ml In 1 Bottle
3
N N N N Y $45None$45None$45None
Mestinon 180mg 30 Tablet, Extended Release In 1 Bottle
3
N N N N Y $45None$45None$45None
Metformin Hydrochloride 500mg 100 Tablet, Extended Release In 1 Bottle
1
120 30 N N Y $5None$5None$5None
Metformin Hydrochloride 850mg 100 Tablet In 1 Bottle
1
90 30 N N Y $5None$5None$5None
Metformin Hydrochloride 750mg 100 Tablet, Extended Release In 1 Bottle
1
60 30 N N Y $5None$5None$5None
Metformin Hydrochloride 1000mg 60 Tablet, Extended Release In 1 Bottle
1
N N N N Y $5None$5None$5None
Metformin Hydrochloride 500mg 1000 Tablet, Film Coated In 1 Bottle
1
150 30 N N Y $5None$5None$5None
Metformin Hydrochloride 1000mg 500 Tablet, Film Coated In 1 Bottle
1
75 30 N N Y $5None$5None$5None
Methadone Hydrochloride 5mg 100 Tablet In 1 Bottle
2
360 30 N N Y $15None$15None$15None
Methadone Hydrochloride 10mg 100 Tablet In 1 Bottle
2
360 30 N N Y $15None$15None$15None
Methadone Hydrochloride 5mg/5mL 500 Ml In 1 Bottle
2
1800 30 N N Y $15None$15None$15None
Methadone Hydrochloride 10mg/5mL 500 Ml In 1 Bottle
2
900 30 N N Y $15None$15None$15None
Methazolamide 50mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Methazolamide 25mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Methimazole 5mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Methimazole 10mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Methotrexate 2.5mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Methotrexate 25mg/mL 1 Vial In 1 Carton > 40 Ml In 1 Vial
2
N N Y N Y $15None$15None$15None
Methoxsalen 10mg 50 Capsule, Liquid Filled In 1 Bottle, Glass
5
N N N N N 33%None33%None33%None
Methyldopa 500mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Methyldopa 250mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Methylphenidate Hcl 10mg 100 Tablet In 1 Bottle, Plastic
2
6 1 N N Y $15None$15None$15None
Methylphenidate Hcl 20mg 100 Tablet In 1 Bottle, Plastic
2
3 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 50mg 100 Capsule, Extended Release In 1 Bottle
2
1 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 60mg 100 Capsule, Extended Release In 1 Bottle
2
1 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 10mg 100 Capsule, Extended Release In 1 Bottle
2
3 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 27mg 100 Tablet In 1 Bottle
2
2 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 36mg 100 Tablet In 1 Bottle
2
2 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 54mg 100 Tablet In 1 Bottle
2
1 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 5mg 100 Tablet In 1 Bottle
2
6 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 10mg 100 Tablet, Extended Release In 1 Bottle
2
4 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 20mg 100 Tablet, Extended Release In 1 Bottle
2
3 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 18mg 100 Tablet, Extended Release In 1 Bottle
2
3 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 20mg 100 Capsule, Extended Release In 1 Bottle
2
3 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 30mg 100 Capsule, Extended Release In 1 Bottle
2
2 1 N N Y $15None$15None$15None
Methylphenidate Hydrochloride 40mg 100 Capsule, Extended Release In 1 Bottle
2
1 1 N N Y $15None$15None$15None
Methylprednisolone 4mg 100 Tablet In 1 Bottle
2
N N Y N Y $15None$15None$15None
Methylprednisolone 4mg 1 Blister Pack In 1 Carton > 21 Tablet In 1 Blister Pack
2
N N Y N Y $15None$15None$15None
Methylprednisolone 8mg 25 Tablet In 1 Bottle
2
N N Y N Y $15None$15None$15None
Methylprednisolone 16mg 50 Tablet In 1 Bottle
2
N N Y N Y $15None$15None$15None
Methylprednisolone 32mg 25 Tablet In 1 Bottle
2
N N Y N Y $15None$15None$15None
Methylprednisolone Acetate 40mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
N N Y N Y $15None$15None$15None
Methylprednisolone Acetate 80mg/mL 25 Vial, Single-dose In 1 Tray > 1 Ml In 1 Vial, Single-dose
2
N N Y N Y $15None$15None$15None
Metoclopramide 10mg 500 Tablet In 1 Bottle
1
N N N N Y $5None$5None$5None
Metoclopramide 5mg/mL 25 Vial In 1 Tray > 2 Ml In 1 Vial
2
N N N N Y $15None$15None$15None
Metoclopramide 5mg/5mL 473 Ml In 1 Bottle, Plastic
1
N N N N Y $5None$5None$5None
Metoclopramide Hydrochloride 5mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y $5None$5None$5None
Metolazone 2.5mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metolazone 5mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metolazone 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metoprolol Succinate 25mg 100 Tablet, Extended Release In 1 Bottle
2
N N N N Y $15None$15None$15None
Metoprolol Succinate 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N N N Y $15None$15None$15None
Metoprolol Succinate 50mg 100 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metoprolol Succinate 100mg 100 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metoprolol Tartrate 100mg 1000 Tablet, Film Coated In 1 Bottle
1
N N N N Y $5None$5None$5None
Metoprolol Tartrate 50mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $5None$5None$5None
Metoprolol Tartrate 25mg 100 Tablet, Film Coated In 1 Bottle
1
N N N N Y $5None$5None$5None
Metoprolol Tartrate And Hydrochlorothiazide 25; 50mg/1; mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metoprolol Tartrate And Hydrochlorothiazide 25; 100mg/1; mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metoprolol Tartrate And Hydrochlorothiazide 50; 100mg/1; mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metronidazole 7.5mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N N Y $15None$15None$15None
Metronidazole 7.5mg/g 45 G In 1 Tube
2
N N N N Y $15None$15None$15None
Metronidazole 7.5mg/mL 59 Ml In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Metronidazole 7.5mg/g 1 Tube, With Applicator In 1 Carton > 70 G In 1 Tube, With Applicator
2
N N N N Y $15None$15None$15None
Metronidazole 10mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
2
N N N N Y $15None$15None$15None
Metronidazole 500mg/100mL 24 Bag In 1 Carton > 100 Ml In 1 Bag
2
N N N N Y $15None$15None$15None
Metronidazole 250mg 250 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Metronidazole 500mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Mexiletine Hydrochloride 150mg 100 Capsule In 1 Bottle
2
N N N N Y $15None$15None$15None
Mexiletine Hydrochloride 200mg 100 Capsule In 1 Bottle
2
N N N N Y $15None$15None$15None
Mexiletine Hydrochloride 250mg 100 Capsule In 1 Bottle
2
N N N N Y $15None$15None$15None
Miacalcin 200[iU]/mL 2 Ml In 1 Vial
3
N N Y N Y $45None$45None$45None
Microgestin .02; 1mg/1; mg 6 Blister Pack In 1 Carton > 21 Tablet In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Microgestin .03; 1.5mg/1; mg 6 Blister Pack In 1 Carton > 21 Tablet In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Microgestin Fe 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Microgestin Fe 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Midodrine Hcl 2.5mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Midodrine Hcl 5mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Midodrine Hcl 10mg 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Migergot 100; 2mg/1; mg 12 Suppository In 1 Box
2
24 30 N N Y $15None$15None$15None
Millipred 5mg/5mg 5 Mg In 1 Bottle
3
N N N N Y $45None$45None$45None
Mimvey 1; .5mg/1; mg 1 Blister Pack In 1 Carton > 28 Tablet, Film Coated In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Mimvey Lo .5; .1mg/1; mg 1 Blister Pack In 1 Carton > 28 Tablet In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Minitran 9mg 30 Patch In 1 Carton
2
N N N N Y $15None$15None$15None
Minitran 18mg 30 Patch In 1 Carton
2
N N N N Y $15None$15None$15None
Minitran 36mg 30 Patch In 1 Carton
2
N N N N Y $15None$15None$15None
Minitran 54mg 30 Patch In 1 Carton
2
N N N N Y $15None$15None$15None
Minocycline Hydrochloride 75mg 100 Capsule In 1 Bottle
2
N N N N Y $15None$15None$15None
Minocycline Hydrochloride 50mg 100 Capsule In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Minocycline Hydrochloride 100mg 50 Capsule In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Minoxidil 2.5mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Minoxidil 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Mirapex .375mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirapex 1.5mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirapex 3mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirapex 4.5mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirapex .75mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirapex 2.25mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirapex 3.75mg 1 Bottle, Plastic In 1 Carton > 30 Tablet, Extended Release In 1 Bottle, Plastic
3
N N N N Y $45None$45None$45None
Mirtazapine 15mg 5 Blister Pack In 1 Box
2
N N N N Y $15None$15None$15None
Mirtazapine 30mg 5 Blister Pack In 1 Box
2
N N N N Y $15None$15None$15None
Mirtazapine 45mg 10 Blister Pack In 1 Box
2
N N N N Y $15None$15None$15None
Mirtazapine 15mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Mirtazapine 30mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N Y $15None$15None$15None
Mirtazapine 7.5mg 30 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Mirtazapine 45mg 500 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Misoprostol 100ug 60 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Misoprostol 200ug 100 Tablet In 1 Bottle
2
N N N N Y $15None$15None$15None
Mitomycin 20mg/40mL 1 Vial In 1 Box, Unit-dose > 40 Ml In 1 Vial
2
N N Y N Y $15None$15None$15None
Mitoxantrone 2mg/mL 12.5 Ml In 1 Vial, Multi-dose
2
N N Y N Y $15None$15None$15None
Moexipril Hydrochloride 7.5mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Moexipril Hydrochloride 15mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Moexipril Hydrochloride And Hydrochlorothiazide 12.5; 7.5mg/1; mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Moexipril Hydrochloride And Hydrochlorothiazide 12.5; 15mg/1; mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Moexipril Hydrochloride And Hydrochlorothiazide 25; 15mg/1; mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Mometasone Furoate 1mg/g 1 Bottle In 1 Carton > 55 G In 1 Bottle
2
N N N N Y $15None$15None$15None
Mometasone Furoate 1mg/g 15 G In 1 Tube
2
N N N N Y $15None$15None$15None
Mometasone Furoate 1mg/g 45 G In 1 Tube
2
N N N N Y $15None$15None$15None
Mononessa 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Montelukast 10mg 30 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Montelukast Sodium 4mg 30 Packet In 1 Carton
2
N N N N Y $15None$15None$15None
Montelukast Sodium 4mg 500 Tablet, Chewable In 1 Bottle
2
N N N N Y $15None$15None$15None
Montelukast Sodium 5mg 500 Tablet, Chewable In 1 Bottle
2
N N N N Y $15None$15None$15None
Monurol 3g 1 Powder In 1 Packet
3
N N N N Y $45None$45None$45None
Morphine Sulfate 15mg 100 Tablet In 1 Bottle
2
240 30 N N Y $15None$15None$15None
Morphine Sulfate 30mg 100 Tablet In 1 Bottle
2
120 30 N N Y $15None$15None$15None
Morphine Sulfate 10mg/5mL 100 Ml In 1 Bottle
2
1800 30 N N Y $15None$15None$15None
Morphine Sulfate 20mg/5mL 100 Ml In 1 Bottle
2
900 30 N N Y $15None$15None$15None
Morphine Sulfate 100mg/5mL 15 Ml In 1 Bottle
2
180 30 N N Y $15None$15None$15None
Morphine Sulfate 15mg 100 Tablet, Extended Release In 1 Bottle
2
4 1 N N Y $15None$15None$15None
Morphine Sulfate 30mg 100 Tablet, Extended Release In 1 Bottle
2
4 1 N N Y $15None$15None$15None
Morphine Sulfate 60mg 100 Tablet, Extended Release In 1 Bottle
2
2 1 N N Y $15None$15None$15None
Moviprep 1 Kit In 1 Container * 1 L In 1 Pouch * 1 L In 1 Pouch
3
N N N N Y $45None$45None$45None
Moxifloxacin Hydrochloride 400mg 30 Tablet, Film Coated In 1 Bottle
2
N N N N Y $15None$15None$15None
Mozobil 24mg/1.2mL 1 Vial, Single-use In 1 Carton > 1.2 Ml In 1 Vial, Single-use
5
N N Y N N 33%None33%None33%None
Multaq 400mg 60 Tablet, Film Coated In 1 Bottle
3
N N Y N Y $45None$45None$45None
Mupirocin 20mg/g 22 G In 1 Tube
2
N N N N Y $15None$15None$15None
Mupirocin 2g/100g 30 G In 1 Tube
2
N N N N Y $15None$15None$15None
Mustargen 10mg/10mL 4 Vial, Single-dose In 1 Box > 10 Ml In 1 Vial, Single-dose
4
N N Y N Y $95None$95None$95None
Mycophenolate Mofetil 500mg 500 Tablet In 1 Bottle
2
N N Y N Y $15None$15None$15None
Mycophenolate Mofetil 250mg 100 Blister Pack In 1 Box, Unit-dose
2
N N Y N Y $15None$15None$15None
Myorisan 10mg 10 Blister Pack In 1 Carton > 10 Capsule, Liquid Filled In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Myorisan 20mg 10 Blister Pack In 1 Carton > 10 Capsule, Liquid Filled In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Myorisan 40mg 10 Blister Pack In 1 Carton > 10 Capsule, Liquid Filled In 1 Blister Pack
2
N N N N Y $15None$15None$15None
Myozyme 5mg/mL 1 Vial, Single-use In 1 Carton > 10.5 Ml In 1 Vial, Single-use
5
N N Y N N 33%None33%None33%None
Myrbetriq 25mg 10 Blister Pack In 1 Carton > 10 Tablet, Film Coated, Extended Release In 1 Blister Pack
3
N N N N Y $45None$45None$45None
Myrbetriq 50mg 1 Bottle In 1 Carton > 90 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N N N Y $45None$45None$45None



Medicare Help's

Additional Notes:



Coverage Levels for H2462-011

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $160. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $2960
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4700 in 2015.
4.Catastrophic: Anything over $4700 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2015 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2014
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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