2009 Medicare Part D Plan Formulary Information |
Prescriba Rx Gold (S5597-062-0)
Benefit Details
|
The Prescriba Rx Gold (S5597-062-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 30 which includes: OR WA
|
Drugs Starting with Letter N
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
NABUMETONE 500MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NABUMETONE 750MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NADOLOL 160MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NADOLOL 20MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NADOLOL 40MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NADOLOL 80MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NAFAZAIR 0.1% EYE DROPS |
1 |
Generic |
$6.00 | $12.00 | None |
NAFCILLIN FOR INJECTION 1 GM/ML |
1 |
Generic |
$6.00 | $12.00 | None |
NAFCILLIN SODIUM INJECTION 1GM VIAL |
1 |
Generic |
$6.00 | $12.00 | None |
NAFCILLIN SODIUM INJECTION 2GM VIL ADD VANTAGE VIAL |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAFTIN HCL GEL 1% 60GM TUBE |
2 |
Brand |
$44.00 | $88.00 | None |
NAFTIN 1% CREAM |
2 |
Brand |
$44.00 | $88.00 | None |
NAFTIN 1% CREAM |
2 |
Brand |
$44.00 | $88.00 | None |
NAGLAZYME 5MG/5ML VIAL |
3 |
Specialty |
33% | N/A | P |
NALFON 200MG CAPSULE |
2 |
Brand |
$44.00 | $88.00 | None |
NALOXONE 1MG/ML SYRINGE |
1 |
Generic |
$6.00 | $12.00 | None |
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG |
1 |
Generic |
$6.00 | $12.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1 |
Generic |
$6.00 | $12.00 | None |
NAMENDA 10MG TABLET |
2 |
Brand |
$44.00 | $88.00 | Q:60 /30Days |
NAMENDA 10MG/5ML SOLUTION |
2 |
Brand |
$44.00 | $88.00 | P Q:360 /30Days |
NAMENDA 5-10MG TITRATION PK |
2 |
Brand |
$44.00 | $88.00 | Q:49 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA 5MG TABLET |
2 |
Brand |
$44.00 | $88.00 | Q:60 /30Days |
NAPRELAN 375MG TABLET SA |
2 |
Brand |
$44.00 | $88.00 | None |
NAPROXEN 125MG/5ML SUSPEN |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN 375MG TABLET EC |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN 500MG TABLET EC |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN SODIUM 275MG TABLET (100 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN SODIUM 500MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN SODIUM 550MG TABLET (500 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN TABLET 250MG (500 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NAPROXEN TABLET 500MG (50 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARDIL 15MG TABLET |
2 |
Brand |
$44.00 | $88.00 | None |
NASONEX 50MCG NASAL SPRAY |
2 |
Brand |
$44.00 | $88.00 | Q:34 /30Days |
NATACYN EYE DROPS |
2 |
Brand |
$44.00 | $88.00 | None |
NAVANE 20MG CAPSULE |
2 |
Brand |
$44.00 | $88.00 | None |
NECON 0.5/35-28 TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NECON 1-0.05MG TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NECON 1/35-28 TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NECON 10/11-28 TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NECON 7 DAYS X 3 TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NEFAZODONE HCL 100MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEFAZODONE HCL 200MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NEFAZODONE HCL 250MG TABLET (60 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NEFAZODONE HCL 50MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NEO/POLY/DEX OIN 0.1% OP |
1 |
Generic |
$6.00 | $12.00 | None |
NEO/POLY/DEXAMET EYE OINT |
1 |
Generic |
$6.00 | $12.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-1 SOLUTION NON-ORAL |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
1 |
Generic |
$6.00 | $12.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1 |
Generic |
$6.00 | $12.00 | None |
NEORAL 100MG GELATN CAPSULE |
2 |
Brand |
$44.00 | $88.00 | P |
NEORAL 100MG/ML SOLUTION |
2 |
Brand |
$44.00 | $88.00 | P |
NEORAL 25MG GELATIN CAPSULE |
2 |
Brand |
$44.00 | $88.00 | P |
NEPHRAMINE SOLUTION FOR INJECTION |
2 |
Brand |
$44.00 | $88.00 | P |
NEULASTA 6MG/0.6ML SYRINGE |
3 |
Specialty |
33% | N/A | P S Q:1 /42Days |
NEUMEGA 5MG VIAL |
3 |
Specialty |
33% | N/A | Q:21 /21Days |
NEUPOGEN 300MCG/ML VIAL |
3 |
Specialty |
33% | N/A | P Q:22 /21Days |
NEUPOGEN INJECTION 300MCG/0.5ML 0.5ML SYR |
3 |
Specialty |
33% | N/A | P Q:7 /21Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
3 |
Specialty |
33% | N/A | P Q:11 /21Days |
NEUPOGEN SOLUTION FOR INJECTION 300MCG/ML 10 X 1ML VIALSD |
3 |
Specialty |
33% | N/A | P Q:14 /21Days |
NEURONTIN 250MG/5ML TUBEX |
2 |
Brand |
$44.00 | $88.00 | None |
NEVANAC 0.1% DROPTAINER |
2 |
Brand |
$44.00 | $88.00 | Q:3 /30Days |
NEXAVAR 200MG TABLET |
3 |
Specialty |
33% | N/A | P Q:120 /30Days |
NEXIUM 10MG PACKET |
2 |
Brand |
$44.00 | $88.00 | Q:30 /30Days |
NEXIUM 20MG CAPSULE |
2 |
Brand |
$44.00 | $88.00 | Q:30 /30Days |
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET |
2 |
Brand |
$44.00 | $88.00 | Q:30 /30Days |
NEXIUM 40MG CAPSULE |
2 |
Brand |
$44.00 | $88.00 | Q:30 /30Days |
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
2 |
Brand |
$44.00 | $88.00 | Q:30 /30Days |
NEXIUM IV 20MG VIAL |
2 |
Brand |
$44.00 | $88.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEXIUM IV 40MG VIAL |
2 |
Brand |
$44.00 | $88.00 | P |
NIACOR 500MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NIASPAN 1000MG TABLET (90 CT) |
2 |
Brand |
$44.00 | $88.00 | Q:60 /30Days |
NIASPAN ER 500MG TABLET (90 CT) |
2 |
Brand |
$44.00 | $88.00 | Q:90 /30Days |
NIASPAN ER 750MG TABLET (90 CT) |
2 |
Brand |
$44.00 | $88.00 | Q:60 /30Days |
NICARDIPINE HCL 20MG CAPSULE (100 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NICARDIPINE HCL 30MG CAPSULE (100 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NIFEDIAC CC 30MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | S Q:30 /30Days |
NIFEDIAC CC 60MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | S Q:30 /30Days |
NIFEDIAC CC 90MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | S |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Generic |
$6.00 | $12.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Generic |
$6.00 | $12.00 | S Q:30 /30Days |
NIFEDIPINE ER 30MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | S Q:30 /30Days |
NIFEDIPINE ER 60MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | S Q:30 /30Days |
NIFEDIPINE ER 90MG TABLET SA |
1 |
Generic |
$6.00 | $12.00 | S |
NILANDRON 150MG TABLET |
2 |
Brand |
$44.00 | $88.00 | None |
NIMODIPINE 30MG CAPSULE |
1 |
Generic |
$6.00 | $12.00 | None |
NITRO-DUR 0.3MG/HR PATCH |
2 |
Brand |
$44.00 | $88.00 | None |
NITRO-DUR 0.8MG/HR PATCH INST. |
2 |
Brand |
$44.00 | $88.00 | None |
NITROFURANTOIN 100MG CAPSULE (100 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NITROFURANTOIN MACROCRYSTAL USP 100MG CAPSULE (100 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
NITROFURANTOIN MCR 50MG CAP |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN .2MG/HR PATCH |
1 |
Generic |
$6.00 | $12.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
1 |
Generic |
$6.00 | $12.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
1 |
Generic |
$6.00 | $12.00 | None |
NITROGLYCERIN PATCHES TRANSDERMAL SYSTEM 0.4MG/HR 30 BOX |
1 |
Generic |
$6.00 | $12.00 | None |
NITROGLYCERIN PATCHES TRANSDERMAL SYSTEM 0.6MG/HR 30 BOX |
1 |
Generic |
$6.00 | $12.00 | None |
NITROGLYCERIN TRANSDERMAL SYSTEM 0.2MG/HR 30 UNITS BOX |
1 |
Generic |
$6.00 | $12.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1 |
Generic |
$6.00 | $12.00 | None |
NITROLINGUAL SPR PUMPSPRA |
2 |
Brand |
$44.00 | $88.00 | None |
NITROSTAT 0.3MG TABLET SL |
2 |
Brand |
$44.00 | $88.00 | None |
NITROSTAT 0.4MG TABLET SL |
2 |
Brand |
$44.00 | $88.00 | None |
NITROSTAT 0.6MG TABLET SL |
2 |
Brand |
$44.00 | $88.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIZATIDINE 150MG CAPSULE |
1 |
Generic |
$6.00 | $12.00 | None |
NIZATIDINE 300MG CAPSULE |
1 |
Generic |
$6.00 | $12.00 | None |
NORA-BE 0.35MG TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NORDITROPIN 15MG/1.5ML CRTG |
3 |
Specialty |
33% | N/A | P Q:13 /28Days |
NORDITROPIN 5MG/1.5ML CRTG |
3 |
Specialty |
33% | N/A | P Q:39 /28Days |
NORDITROPIN NORDIFLEX 10MG/1.5 |
3 |
Specialty |
33% | N/A | P Q:13 /28Days |
NORDITROPIN NORDIFLEX 15MG/1.5 |
3 |
Specialty |
33% | N/A | P Q:13 /28Days |
NORDITROPIN NORDIFLEX 5MG/1.5 |
3 |
Specialty |
33% | N/A | P Q:39 /28Days |
NORETHINDRONE 5MG TABLET |
1 |
Generic |
$6.00 | $12.00 | None |
NORITATE 1% CREAM |
2 |
Brand |
$44.00 | $88.00 | None |
NORMOSOL -R INJ /D5W |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORMOSOL-M AND DEXTROSE 5% |
1 |
Generic |
$6.00 | $12.00 | None |
NORMOSOL-R IV SOLUTION |
1 |
Generic |
$6.00 | $12.00 | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
2 |
Brand |
$44.00 | $88.00 | None |
NORPACE CR 100MG CAPSULE SA |
2 |
Brand |
$44.00 | $88.00 | None |
NORTREL .035-1MG TABLET 21DAY BLPK |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NORTREL 0.035-0.5MG TABLET 28DAY BLPK |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NORTREL 1-0.035MG TABLET 28DAY |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NORTREL 7 DAYS X 3 TABLET |
1 |
Generic |
$6.00 | $12.00 | Q:28 /28Days |
NORTRIPTYLINE 10MG/5ML SOL |
1 |
Generic |
$6.00 | $12.00 | None |
NORTRIPTYLINE HCL 10MG CAPSULE |
1 |
Generic |
$6.00 | $12.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTRIPTYLINE HCL 50MG CAPSULE |
1 |
Generic |
$6.00 | $12.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Generic |
$6.00 | $12.00 | None |
NORVIR 100MG SOFTGEL CAP 120 CAPS BOTPL |
2 |
Brand |
$44.00 | $88.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Specialty |
33% | N/A | None |
NOVAMINE AMINO ACIDS INJECTION 15% |
1 |
Generic |
$6.00 | $12.00 | P |
NOVOLIN 70/30 100U/ML VIAL |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN 70/30 U100 CARTRIDG |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN 70/INJ 30 INNLT |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN N 100U/ML CARTRIDGE |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN N 100U/ML VIAL |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN N INJ INNOLET |
2 |
Brand |
$44.00 | $88.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NOVOLIN R 100U/ML CARTRIDGE |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN R 100U/ML VIAL |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLIN R 100UNIT/ML INNOLET |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLOG 100U/ML CARTRIDGE |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLOG 100U/ML VIAL |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLOG FLEXPEN SYRINGE |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLOG MIX 70/30 CARTRIDGE |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
2 |
Brand |
$44.00 | $88.00 | None |
NOVOLOG MIX 70/30 VIAL |
2 |
Brand |
$44.00 | $88.00 | None |
NULYTELY POWDER FOR ORAL SOLUTION 420GM-1.48GM-5GM 4L BOT |
2 |
Brand |
$44.00 | $88.00 | None |
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT |
2 |
Brand |
$44.00 | $88.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUTROPIN 10MG VIAL |
3 |
Specialty |
33% | N/A | P Q:6 /28Days |
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN |
3 |
Specialty |
33% | N/A | P Q:12 /28Days |
NUTROPIN AQ INJ 10MG/2ML |
3 |
Specialty |
33% | N/A | P Q:22 /28Days |
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML |
3 |
Specialty |
33% | N/A | P Q:22 /28Days |
NUTROPIN SOMATROPIN RDNAORIGIN FOR INJECTION 5MG 1 VIAL |
3 |
Specialty |
33% | N/A | P Q:6 /28Days |
NYAMYC 100000 U/G POWDER |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTATIN 100000U/G POWDER |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTATIN 100000U/GM CREAM |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTATIN 100000U/GM OINT |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTATIN ORAL SUSPENSION 100000U 473ML BOT |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN/TRIAMCINOLONE CRM |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
1 |
Generic |
$6.00 | $12.00 | None |
NYSTOP 100000U/GM POWDER |
1 |
Generic |
$6.00 | $12.00 | None |