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Health Net Orange Option 1 (PDP) (S5678-056-0)
Tier 1 (1401)
Tier 2 (633)
Tier 3 (558)
Tier 4 (668)
Tier 5 (286)
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2011 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (PDP) (S5678-056-0)
Sanctioned Plan           
The Health Net Orange Option 1 (PDP) (S5678-056-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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   4 Tier 4 Injectable 25%25%None
MACRODANTIN 25MG CAPSULE   2 Tier 2 Preferred Brand $37.00$74.00None
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR   4 Tier 4 Injectable 25%25%None
MAGNESIUM SULFATE 4% IV SOLUTION   4 Tier 4 Injectable 25%25%None
MAGNESIUM SULFATE 8% IV SOLUTION   4 Tier 4 Injectable 25%25%None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   4 Tier 4 Injectable 25%25%None
MALARONE 250-100MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MALARONE 62.5-25MG PED TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MAPROTILINE 25MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MAPROTILINE 50MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAPROTILINE 75MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MARGESIC H 5MG-500MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
MARPLAN 10MG TABLET (100 CT)   2 Tier 2 Preferred Brand $37.00$74.00None
MATULANE 50MG CAPSULE   5 Tier 5 Specialty 25%25%None
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MAXIPIME 1G VIAL   4 Tier 4 Injectable 25%25%None
MAXIPIME 2G ADD-VANTAGE VL   4 Tier 4 Injectable 25%25%None
MEBENDAZOLE 100MG TABLET CHEW   1 Tier 1 Preferred Generic $4.00$8.00None
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
MEDROXYPROGESTERONE 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEDROXYPROGESTERONE 2.5MG   1 Tier 1 Preferred Generic $4.00$8.00None
MEDROXYPROGESTERONE 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   4 Tier 4 Injectable 25%25%None
MEFLOQUINE HCL 250MG TABLET 25 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
MEGACE ES 625MG/5ML SUSP   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MEGESTROL 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL   1 Tier 1 Preferred Generic $4.00$8.00None
MEGESTROL ACETATE 40MG TABLET (250 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
MELOXICAM 15MG TABLET (500 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
MELOXICAM TABLETS 7.5MG   1 Tier 1 Preferred Generic $4.00$8.00None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   4 Tier 4 Injectable 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR   4 Tier 4 Injectable 25%25%None
MENEST 0.3MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
MENEST 0.625MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
MENEST 1.25MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
MENEST 2.5MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
MENOMUNE-A/C/Y/W-135 VIAL   4 Tier 4 Injectable 25%25%None
MENOSTAR 14 MCG/DAY PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MENTAX 1% CREAM 15G TUBE   2 Tier 2 Preferred Brand $37.00$74.00None
MEPERIDINE 10MG/ML SYRINGE   4 Tier 4 Injectable 25%25%None
MEPERIDINE 25MG/ML VIAL   4 Tier 4 Injectable 25%25%None
MEPERIDINE 50MG/5ML SYRUP   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEPERIDINE 50MG/ML VIAL   4 Tier 4 Injectable 25%25%None
MEPERIDINE HCL 50MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
MEPERIDINE HCL INJECTION 75MG 25 X 1ML VIALSD   4 Tier 4 Injectable 25%25%None
MEPERIDINE HCL TABLET 100MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
MEPERIDINE HYDROCHLORIDE INJECTION 100MG/ML 25 X 1 ML VIALSD   4 Tier 4 Injectable 25%25%None
MEPRON 750MG/5ML ORAL SUSP   5 Tier 5 Specialty 25%25%None
MERCAPTOPURINE 50MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MERREM INJECTION 500MG 10X20MLVIALS VIAL   4 Tier 4 Injectable 25%25%None
MERUVAX II VACCINE/DILUENT   4 Tier 4 Injectable 25%25%None
MESALAMINE 4G/60ML ENEMA   1 Tier 1 Preferred Generic $4.00$8.00None
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN   4 Tier 4 Injectable 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESNEX 100MG/ML VIAL   4 Tier 4 Injectable 25%25%None
MESNEX 400MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
MESTINON 180MG TIMESPAN   2 Tier 2 Preferred Brand $37.00$74.00None
MESTINON 60MG/5ML SYRUP   2 Tier 2 Preferred Brand $37.00$74.00None
METADATE ER 20MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
METAPROTERENOL 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METAPROTERENOL 10MG/5ML SYR   1 Tier 1 Preferred Generic $4.00$8.00None
METAPROTERENOL 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METFORMIN HCL 1000MG TABLET (500 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METFORMIN HCL 500MG TABLET (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METFORMIN HCL 850MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METFORMIN HCL ER 500MG TABLET SR 24HR   1 Tier 1 Preferred Generic $4.00$8.00None
METFORMIN HCL ER 750MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METHADONE 10MG/5ML SOLUTION   2 Tier 2 Preferred Brand $37.00$74.00None
METHADONE 5MG/5ML SOLUTION   2 Tier 2 Preferred Brand $37.00$74.00None
METHADONE HCL 5MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT   1 Tier 1 Preferred Generic $4.00$8.00None
METHADONE HYDROCHLORIDE INJECTION 10MG/ML   4 Tier 4 Injectable 25%25%None
METHADONE HYDROCHLORIDE TABLETS 10 MG   1 Tier 1 Preferred Generic $4.00$8.00None
METHADOSE 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHADOSE 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHAMPHETAMINE HYDROCHLORIDE TABLETS 5 MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHAZOLAMIDE 25MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHAZOLAMIDE 50MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHENAMINE HIPPURATE 1G TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHERGINE 0.2MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
METHIMAZOLE 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHIMAZOLE 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHITEST 10MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
METHOCARBAMOL 500MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHOCARBAMOL 750MG TABLET (500 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METHOTREXATE 2.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHOTREXATE FOR INJECTION 1 GM/ML   4 Tier 4 Injectable 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHOTREXATE INJECTION 25 MG/ML   4 Tier 4 Injectable 25%25%None
METHYCLOTHIAZIDE 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLDOPA 250MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLDOPA 500MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLDOPA/HCTZ 250-15 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLDOPA/HCTZ 250-25 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLDOPATE 250MG/5ML VIAL   4 Tier 4 Injectable 25%25%None
METHYLIN 10 MG CHEWABLE   2 Tier 2 Preferred Brand $37.00$74.00None
METHYLIN 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLIN 2.5 MG CHEWABLE TAB   2 Tier 2 Preferred Brand $37.00$74.00None
METHYLIN 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLIN 5 MG CHEWABLE TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
METHYLIN ER 10MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLIN ER 20MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLIN SOLUTION 5MG/5ML 500 ML BOT   2 Tier 2 Preferred Brand $37.00$74.00None
METHYLIN TABLET 5MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPHENIDATE 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPHENIDATE 2 MG/ML ORAL SOLUTION [METHYLIN]   2 Tier 2 Preferred Brand $37.00$74.00None
METHYLPHENIDATE 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPHENIDATE 5MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPR ACE INJ 80MG/ML   4 Tier 4 Injectable 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPREDNISOLONE 16MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPREDNISOLONE 1GM VIAL   4 Tier 4 Injectable 25%25%None
METHYLPREDNISOLONE 32MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPREDNISOLONE 4 MG ORAL TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPREDNISOLONE 40MG/ML VL 5ML   4 Tier 4 Injectable 25%25%None
METHYLPREDNISOLONE 8 MG ORAL TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL   4 Tier 4 Injectable 25%25%None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL   4 Tier 4 Injectable 25%25%None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   1 Tier 1 Preferred Generic $4.00$8.00None
METIPRANOLOL 0.3% EYE DROPS   1 Tier 1 Preferred Generic $4.00$8.00None
METOCLOPRAMIDE 10 MG DISINTEGRATING TABLET [METOZOLV]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOCLOPRAMIDE 5 MG DISINTEGRATING TABLET [METOZOLV]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT   1 Tier 1 Preferred Generic $4.00$8.00None
METOCLOPRAMIDE 5MG/ML VIAL   4 Tier 4 Injectable 25%25%None
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL   1 Tier 1 Preferred Generic $4.00$8.00None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT   1 Tier 1 Preferred Generic $4.00$8.00None
METOLAZONE 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METOLAZONE 2.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METOLAZONE 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL SUCCINATE 25MG TABLET SR 24HR   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL SUCCINATE 50MG TABLET SR 24HR   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD   4 Tier 4 Injectable 25%25%None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
METROGEL TOPICAL 1% GEL   2 Tier 2 Preferred Brand $37.00$74.00None
METRONIDAZOLE 0.75% CREAM   1 Tier 1 Preferred Generic $4.00$8.00None
METRONIDAZOLE 0.75% LOTION   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 375MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
METRONIDAZOLE 500MG/100ML   4 Tier 4 Injectable 25%25%None
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL   1 Tier 1 Preferred Generic $4.00$8.00None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL   1 Tier 1 Preferred Generic $4.00$8.00None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   1 Tier 1 Preferred Generic $4.00$8.00None
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MIACALCIN 200IU/ML VIAL   4 Tier 4 Injectable 25%25%None
MICARDIS 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
MICARDIS 40MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
MICARDIS 80MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
MICARDIS HCT 40/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MICARDIS HCT 80/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
MICARDIS HCT 80/25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
MICONAZOLE 3 200MG SUPPOS.   1 Tier 1 Preferred Generic $4.00$8.00None
MICROGESTIN 1-0.02MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MICROGESTIN 1.5-0.03MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MICROGESTIN FE 1.5/30 TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MICROGESTIN FE 1/20 TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MIGERGOT 2-100MG SUPPOSITORY RECTAL   2 Tier 2 Preferred Brand $37.00$74.00None
MILLIPRED TABLETS 5MG   2 Tier 2 Preferred Brand $37.00$74.00None
MINITRAN 0.1MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic $4.00$8.00None
MINITRAN 0.2MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINITRAN 0.4MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic $4.00$8.00None
MINITRAN 0.6MG/HR PATCH 30 EA   1 Tier 1 Preferred Generic $4.00$8.00None
MINOCYCLINE 100MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
MINOCYCLINE 50MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
MINOCYCLINE HCL 75MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
MINOXIDIL 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MINOXIDIL 2.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MIRTAZAPINE 15MG TABLET (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRTAZAPINE TABLET 30MG (30 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MIRTAZAPINE TABLET 7.5MG (30 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MIRTAZAPINE TABLETS 45MG 30 BOT   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MISOPROSTOL 100MCG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MISOPROSTOL 200MCG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL   4 Tier 4 Injectable 25%25%None
MITOXANTRONE INJECTION 2MG 125ML VIAL   4 Tier 4 Injectable 25%25%None
MOEXIPRIL HCL 15MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:4
/1Days
MOEXIPRIL HCL 7.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:6
/1Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:2
/1Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:4
/1Days
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE   1 Tier 1 Preferred Generic $4.00$8.00None
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE   1 Tier 1 Preferred Generic $4.00$8.00None
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%   1 Tier 1 Preferred Generic $4.00$8.00Q:5
/1Days
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
MORPHINE SULFATE 100MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE 15MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE 15MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE 20 MG/ML SOL   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE 200MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE 30MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE 5MG 25 X 1ML VIAL   4 Tier 4 Injectable 25%25%None
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL   4 Tier 4 Injectable 25%25%None
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL   4 Tier 4 Injectable 25%25%None
MORPHINE SULFATE ORAL SOLUTION   2 Tier 2 Preferred Brand $37.00$74.00None
MORPHINE SULFATE ORAL SOLUTION   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE TABLET 30 MG   1 Tier 1 Preferred Generic $4.00$8.00None
MORPHINE SULFATE TABLET ER 60MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
MOTOFEN TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MOVIPREP 7.5-2.691G POWDER IN PACKET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MOZOBIL SOLUTION 24MG/1.2ML   5 Tier 5 Specialty 25%25%None
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT   2 Tier 2 Preferred Brand $37.00$74.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MUPIROCIN 2% OINTMENT   1 Tier 1 Preferred Generic $4.00$8.00None
MUSTARGEN 10MG VIAL   4 Tier 4 Injectable 25%25%None
MYCAMINE 50MG VIAL   5 Tier 5 Specialty 25%25%None
MYCAMINE FOR INJECTION SOLUTION   5 Tier 5 Specialty 25%25%None
MYCOBUTIN 150MG CAPSULE   2 Tier 2 Preferred Brand $37.00$74.00None
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT   1 Tier 1 Preferred Generic $4.00$8.00P
MYDRAL 0.5% DROPS   1 Tier 1 Preferred Generic $4.00$8.00None
MYDRAL 1% DROPS   1 Tier 1 Preferred Generic $4.00$8.00None
MYDRIACYL 1% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MYFORTIC 180MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MYFORTIC 360MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
MYOBLOC 5000UNITS/1ML VIAL   4 Tier 4 Injectable 25%25%P
MYOZYME 50MG VIAL   5 Tier 5 Specialty 25%25%P
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
MYTELASE 10MG CAPLET   2 Tier 2 Preferred Brand $37.00$74.00None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Health Net Orange Option 1 (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug 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).

  • 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 $310 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 October 2011 )

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 Part D plan provider.







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.