2013 Medicare Part D Plan Formulary Information |
SCAN Connections (HMO SNP) (H5425-010-0)
Benefit Details
|
The SCAN Connections (HMO SNP) (H5425-010-0) Formulary Drugs Starting with the Letter M in Statewide County, CA: CMS MA Region 24 which includes: CA
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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 |
Tier 3 |
N/A | N/A | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
2 |
Tier 2 |
N/A | N/A | None |
MALARONE 62.5-25MG PED TABLET |
4 |
Tier 4 |
N/A | N/A | None |
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
MAPROTILINE 25MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MAPROTILINE 50MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MAPROTILINE 75MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MARLISSA-28 TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MARPLAN 10MG TABLET (100 CT) |
4 |
Tier 4 |
N/A | N/A | None |
MATULANE 50MG CAPSULE |
5 |
Tier 5 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
2 |
Tier 2 |
N/A | N/A | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
2 |
Tier 2 |
N/A | N/A | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
2 |
Tier 2 |
N/A | N/A | None |
MEGACE ES 625MG/5ML SUSP |
4 |
Tier 4 |
N/A | N/A | None |
MEGESTROL 20MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
2 |
Tier 2 |
N/A | N/A | None |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
Meloxicam 15mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MELOXICAM 7.5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
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 |
Tier 3 |
N/A | N/A | None |
MENEST 0.3MG TABLET |
3 |
Tier 3 |
N/A | N/A | None |
MENEST 0.625MG TABLET |
3 |
Tier 3 |
N/A | N/A | None |
MENEST 1.25MG TABLET |
3 |
Tier 3 |
N/A | N/A | None |
MENEST 2.5MG TABLET |
3 |
Tier 3 |
N/A | N/A | None |
MENOMUNE-A/C/Y/W-135 VIAL |
3 |
Tier 3 |
N/A | N/A | None |
MENVEO INJECTION KIT |
3 |
Tier 3 |
N/A | N/A | None |
MEPRON 750MG/5ML ORAL SUSP |
5 |
Tier 5 |
N/A | N/A | None |
MERCAPTOPURINE 50MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
Mesalamine 1 KIT in 1 CARTON |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESNEX 400MG TABLET |
3 |
Tier 3 |
N/A | N/A | None |
MESTINON 180MG TIMESPAN |
3 |
Tier 3 |
N/A | N/A | None |
MESTINON 60MG/5ML SYRUP |
3 |
Tier 3 |
N/A | N/A | None |
METADATE ER 20MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
N/A | N/A | None |
Metformin Hydrochloride 750mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
METHADONE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methadone Hydrochloride 10mg/5mL |
2 |
Tier 2 |
N/A | N/A | None |
Methadone Hydrochloride 10mg/mL |
2 |
Tier 2 |
N/A | N/A | None |
Methadone Hydrochloride 5mg/5mL |
2 |
Tier 2 |
N/A | N/A | None |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
2 |
Tier 2 |
N/A | N/A | None |
METHADOSE 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METHAZOLAMIDE 25MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METHAZOLAMIDE 50MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
Methimazole 10mg/1 |
2 |
Tier 2 |
N/A | N/A | None |
METHIMAZOLE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
Methocarbamol 500mg 100 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | P |
METHOCARBAMOL 750MG TABLET (500 CT) |
2 |
Tier 2 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOTREXATE 2.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
Methotrexate 25mg/mL 10 VIAL in 1 BOX, UNIT-DOSE / 8 mL in 1 VIAL |
2 |
Tier 2 |
N/A | N/A | None |
METHOTREXATE FOR INJECTION 1 GM/ML |
2 |
Tier 2 |
N/A | N/A | None |
METHYLDOPA 250MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
METHYLDOPA 500MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
Methyldopa and Hydrochlorothiazide 25; 250mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | P |
METHYLDOPA/HCTZ 250-15 TABLET |
2 |
Tier 2 |
N/A | N/A | P |
METHYLDOPATE 250MG/5ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
METHYLPHENIDATE 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METHYLPHENIDATE 20MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
methylprednisolone 125 mg vial |
2 |
Tier 2 |
N/A | N/A | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
methylprednisolone 40 mg vial |
2 |
Tier 2 |
N/A | N/A | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Methylprednisolone Sodium Succinate 1g/8mL 1 VIAL, SINGLE-DOSE in 1 BOX / 8 mL in 1 VIAL, SINGLE-DO |
2 |
Tier 2 |
N/A | N/A | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
N/A | N/A | None |
METIPRANOLOL 0.3% EYE DROPS |
2 |
Tier 2 |
N/A | N/A | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
2 |
Tier 2 |
N/A | N/A | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Tier 1 |
N/A | N/A | None |
METOLAZONE 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METOLAZONE 2.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METOLAZONE 5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL SUCC ER 100 MG TAB |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL SUCC ER 50 MG TAB |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
METRONIDAZOLE 0.75% CREAM |
2 |
Tier 2 |
N/A | N/A | None |
METRONIDAZOLE 0.75% LOTION |
2 |
Tier 2 |
N/A | N/A | None |
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG |
2 |
Tier 2 |
N/A | N/A | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
2 |
Tier 2 |
N/A | N/A | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
2 |
Tier 2 |
N/A | N/A | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 150MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
MEXILETINE 200MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
MEXILETINE 250MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
MIACALCIN 200IU/ML VIAL |
4 |
Tier 4 |
N/A | N/A | P |
MICROGESTIN 1-0.02MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MICROGESTIN 1.5-0.03MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MIDODRINE HCL 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MIDODRINE HCL 2.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
MINOCYCLINE 100MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
MINOCYCLINE 50MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE HCL 75MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
2 |
Tier 2 |
N/A | N/A | None |
MINOXIDIL 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MINOXIDIL 2.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MIRTAZAPINE 15 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
N/A | N/A | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
N/A | N/A | None |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Mirtazapine 7.5mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
N/A | N/A | None |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
misoprostol 100 mcg tablet |
2 |
Tier 2 |
N/A | N/A | None |
misoprostol 200 mcg tablet |
2 |
Tier 2 |
N/A | N/A | None |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Tier 2 |
N/A | N/A | P |
MODAFINIL 100 MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
MODAFINIL 200 MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
MOEXIPRIL HCL 15MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MOEXIPRIL HCL 7.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
MOMETASONE FUROATE 0.1% SOLN |
2 |
Tier 2 |
N/A | N/A | None |
Mometasone Furoate 1mg/g 45 g in 1 TUBE |
2 |
Tier 2 |
N/A | N/A | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
MONTELUKAST SOD 10 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
montelukast sod 4 mg granules |
2 |
Tier 2 |
N/A | N/A | None |
montelukast sod 4 mg tab chew |
2 |
Tier 2 |
N/A | N/A | None |
montelukast sod 5 mg tab chew |
2 |
Tier 2 |
N/A | N/A | None |
MORPHINE SULFATE 100MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | Q:100 /31Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
MORPHINE SULFATE 15MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | Q:100 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 200MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | Q:100 /31Days |
MORPHINE SULFATE 30MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | Q:100 /31Days |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
MORPHINE SULFATE ORAL SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | Q:100 /31Days |
MORPHINE SULFATE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
MORPHINE SULFATE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
3 |
Tier 3 |
N/A | N/A | None |
mupirocin 2% cream |
2 |
Tier 2 |
N/A | N/A | None |
MUPIROCIN 2% OINTMENT |
2 |
Tier 2 |
N/A | N/A | None |
MYCOBUTIN 150MG CAPSULE |
4 |
Tier 4 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
2 |
Tier 2 |
N/A | N/A | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Tier 2 |
N/A | N/A | P |
MYFORTIC 180MG TABLET |
4 |
Tier 4 |
N/A | N/A | P |
MYFORTIC 360MG TABLET |
4 |
Tier 4 |
N/A | N/A | P |
MYTELASE 10MG CAPLET |
3 |
Tier 3 |
N/A | N/A | None |