2011 Medicare Part D Plan Formulary Information |
Health Net Seniority Plus Amber I (HMO SNP) (H0562-055-0)
Sanctioned Plan
|
The Health Net Seniority Plus Amber I (HMO SNP) (H0562-055-0) Formulary Drugs Starting with the Letter M in San Bernardino County, CA: CMS MA Region 24 which includes: CA
|
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 |
MACRODANTIN 25MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
MAPROTILINE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MAPROTILINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MAPROTILINE 75MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MARGESIC H 5MG-500MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
MARPLAN 10MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
15% | 15% | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
15% | 15% | None |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
1 |
Tier 1 |
15% | 15% | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
15% | 15% | None |
MELOXICAM 15MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
MELOXICAM TABLETS 7.5MG |
1 |
Tier 1 |
15% | 15% | None |
MENEST 0.3MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
MENEST 0.625MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
MENEST 1.25MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENEST 2.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
MENTAX 1% CREAM 15G TUBE |
2 |
Tier 2 |
15% | 15% | None |
MEPERIDINE 50MG/5ML SYRUP |
1 |
Tier 1 |
15% | 15% | None |
MEPERIDINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
MEPERIDINE HCL TABLET 100MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MESALAMINE 4G/60ML ENEMA |
1 |
Tier 1 |
15% | 15% | None |
MESNEX 400MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
MESTINON 180MG TIMESPAN |
2 |
Tier 2 |
15% | 15% | None |
MESTINON 60MG/5ML SYRUP |
2 |
Tier 2 |
15% | 15% | None |
METADATE ER 20MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METAPROTERENOL 10MG/5ML SYR |
1 |
Tier 1 |
15% | 15% | None |
METAPROTERENOL 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
METFORMIN HCL 850MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
15% | 15% | None |
METFORMIN HCL ER 750MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
METHADONE 10MG/5ML SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
METHADONE 5MG/5ML SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT |
1 |
Tier 1 |
15% | 15% | None |
METHADONE HYDROCHLORIDE TABLETS 10 MG |
1 |
Tier 1 |
15% | 15% | None |
METHADOSE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHADOSE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHENAMINE HIPPURATE 1G TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHERGINE 0.2MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
METHIMAZOLE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHIMAZOLE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHITEST 10MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOCARBAMOL 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLDOPA 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLDOPA 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLIN 10 MG CHEWABLE |
2 |
Tier 2 |
15% | 15% | None |
METHYLIN 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
METHYLIN 2.5 MG CHEWABLE TAB |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLIN 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLIN 5 MG CHEWABLE TABLET |
2 |
Tier 2 |
15% | 15% | None |
METHYLIN ER 10MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
METHYLIN ER 20MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
METHYLIN SOLUTION 5MG/5ML 500 ML BOT |
2 |
Tier 2 |
15% | 15% | None |
METHYLIN TABLET 5MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLPHENIDATE 2 MG/ML ORAL SOLUTION [METHYLIN] |
2 |
Tier 2 |
15% | 15% | None |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLPREDNISOLONE 4 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
15% | 15% | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT |
1 |
Tier 1 |
15% | 15% | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Tier 1 |
15% | 15% | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Tier 1 |
15% | 15% | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METROGEL TOPICAL 1% GEL |
2 |
Tier 2 |
15% | 15% | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
15% | 15% | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
15% | 15% | None |
METRONIDAZOLE 375MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Tier 1 |
15% | 15% | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Tier 1 |
15% | 15% | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
MICONAZOLE 3 200MG SUPPOS. |
1 |
Tier 1 |
15% | 15% | None |
MICROGESTIN 1-0.02MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN FE 1.5/30 TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MICROGESTIN FE 1/20 TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
15% | 15% | None |
MILLIPRED TABLETS 5MG |
2 |
Tier 2 |
15% | 15% | None |
MINITRAN 0.1MG/HR PATCH 30 EA |
1 |
Tier 1 |
15% | 15% | None |
MINITRAN 0.2MG/HR PATCH 30 EA |
1 |
Tier 1 |
15% | 15% | None |
MINITRAN 0.4MG/HR PATCH 30 EA |
1 |
Tier 1 |
15% | 15% | None |
MINITRAN 0.6MG/HR PATCH 30 EA |
1 |
Tier 1 |
15% | 15% | None |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MIRTAZAPINE 15MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIRTAZAPINE TABLET 7.5MG (30 CT) |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MIRTAZAPINE TABLETS 45MG 30 BOT |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MISOPROSTOL 100MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
MISOPROSTOL 200MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOEXIPRIL HCL 15MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:4 /1Days |
MOEXIPRIL HCL 7.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:6 /1Days |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:2 /1Days |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:2 /1Days |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:4 /1Days |
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Tier 1 |
15% | 15% | Q:5 /1Days |
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE 15MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE 20 MG/ML SOL |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
MORPHINE SULFATE ORAL SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE TABLET 30 MG |
1 |
Tier 1 |
15% | 15% | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT |
2 |
Tier 2 |
15% | 15% | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
MYCOBUTIN 150MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
Tier 1 |
15% | 15% | P |
MYDRAL 0.5% DROPS |
1 |
Tier 1 |
15% | 15% | None |
MYDRAL 1% DROPS |
1 |
Tier 1 |
15% | 15% | None |
MYTELASE 10MG CAPLET |
2 |
Tier 2 |
15% | 15% | None |