Q1Medicare.com 2010 Medicare Part D or Medicare Advantage Plan Formulary Browser

2010 Medicare Part D Plan Formulary Information
Advantage Freedom Plan by RxAmerica (PDP) (S5644-176-0) Benefit Details
The Advantage Freedom Plan by RxAmerica (PDP) (S5644-176-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 15 which includes: IN KY
Drugs Starting with Letter N Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter N Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NABUMETONE 500MG TABLET	2	Generic	$5.00	$10.00	None
NABUMETONE 750MG TABLET	2	Generic	$5.00	$10.00	None
NADOLOL 160MG TABLET	2	Generic	$5.00	$10.00	None
NADOLOL 20MG TABLET	2	Generic	$5.00	$10.00	None
NADOLOL 40MG TABLET	2	Generic	$5.00	$10.00	None
NADOLOL 80MG TABLET	2	Generic	$5.00	$10.00	None
NAFAZAIR 0.1% EYE DROPS	2	Generic	$5.00	$10.00	None
NAFCILLIN FOR INJECTION 1 GM/ML	2	Generic	$5.00	$10.00	P
NAFCILLIN FOR INJECTION 10GM/ML 1 VIAL	2	Generic	$5.00	$10.00	P
NAGLAZYME 5MG/5ML VIAL	3	Preferred Brand	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NALOXONE 1MG/ML SYRINGE	2	Generic	$5.00	$10.00	P
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG	2	Generic	$5.00	$10.00	P
NALTREXONE HCL 50MG TABLET 100 BLPK	2	Generic	$5.00	$10.00	None
NAMENDA 10MG TABLET	3	Preferred Brand	33%	33%	None
NAMENDA 10MG/5ML SOLUTION	3	Preferred Brand	33%	33%	None
NAMENDA 5-10MG TITRATION PK	3	Preferred Brand	33%	33%	None
NAMENDA 5MG TABLET	3	Preferred Brand	33%	33%	None
NAPROXEN 125MG/5ML SUSPEN	2	Generic	$5.00	$10.00	None
NAPROXEN 375MG TABLET EC	2	Generic	$5.00	$10.00	None
NAPROXEN 500MG TABLET EC	2	Generic	$5.00	$10.00	None
NAPROXEN SODIUM 275MG TABLET (100 CT)	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROXEN SODIUM 550MG TABLET (500 CT)	2	Generic	$5.00	$10.00	None
NAPROXEN TABLET 375MG (500 CT)	1	Value Generic	$2.50	$5.00	None
NARDIL 15MG TABLET	3	Preferred Brand	33%	33%	None
NASACORT AQ AER 55MCG/AC	3	Preferred Brand	33%	33%	None
NATACYN EYE DROPS	3	Preferred Brand	33%	33%	None
NAVANE 20MG CAPSULE	3	Preferred Brand	33%	33%	None
NECON 0.5/35-28 TABLET	2	Generic	$5.00	$10.00	None
NECON 1-0.05MG TABLET	2	Generic	$5.00	$10.00	None
NECON 1/35-28 TABLET	2	Generic	$5.00	$10.00	None
NECON 10/11-28 TABLET	2	Generic	$5.00	$10.00	None
NECON 7 DAYS X 3 TABLET	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEFAZODONE HCL 150MG TABLET (60 CT)	2	Generic	$5.00	$10.00	None
NEFAZODONE HCL 250MG TABLET	2	Generic	$5.00	$10.00	None
NEFAZODONE HCL 50MG TABLET	2	Generic	$5.00	$10.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT	2	Generic	$5.00	$10.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT	2	Generic	$5.00	$10.00	None
NEO-FRADIN 125MG/5ML SOLUTION ORAL	3	Preferred Brand	33%	33%	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	2	Generic	$5.00	$10.00	None
NEOMYCIN SULFATE 500MG TABLET	2	Generic	$5.00	$10.00	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	2	Generic	$5.00	$10.00	None
NEORAL 100MG GELATN CAPSULE	3	Preferred Brand	33%	33%	P
NEORAL 100MG/ML SOLUTION	3	Preferred Brand	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEORAL 25MG GELATIN CAPSULE	3	Preferred Brand	33%	33%	P
NEPHRAMINE SOLUTION FOR INJECTION	3	Preferred Brand	33%	33%	P
NEULASTA 6MG/0.6ML SYRINGE	4	Specialty	33%	N/A	P
NEUMEGA 5MG VIAL	4	Specialty	33%	N/A	P
NEUPOGEN 300MCG/ML VIAL	4	Specialty	33%	N/A	P
NEUPOGEN INJECTION 300MCG/0.5ML 0.5ML SYR	4	Specialty	33%	N/A	P
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR	4	Specialty	33%	N/A	P
NEURONTIN 250MG/5ML TUBEX	3	Preferred Brand	33%	33%	P
NEUTREXIN 25MG VIAL	3	Preferred Brand	33%	33%	P
NEXAVAR TABLETS 200MG 120 BOT	3	Preferred Brand	33%	33%	P
NEXIUM IV 40MG VIAL	5	Non-Preferred	45%	45%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NIASPAN 1000MG TABLET (90 CT)	3	Preferred Brand	33%	33%	None
NIASPAN ER 500MG TABLET (90 CT)	3	Preferred Brand	33%	33%	None
NIASPAN ER 750MG TABLET (90 CT)	3	Preferred Brand	33%	33%	None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL	3	Preferred Brand	33%	33%	P
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL	3	Preferred Brand	33%	33%	P
NIFEDIAC CC 30MG TABLET SA	2	Generic	$5.00	$10.00	None
NIFEDIAC CC 60MG TABLET SA	2	Generic	$5.00	$10.00	None
NIFEDIAC CC 90MG TABLET SA	2	Generic	$5.00	$10.00	None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR	2	Generic	$5.00	$10.00	None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR	2	Generic	$5.00	$10.00	None
NIFEDIPINE 10MG CAPSULE	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NIFEDIPINE 20MG CAPSULE	2	Generic	$5.00	$10.00	None
NIFEDIPINE ER 30MG TABLET SA	2	Generic	$5.00	$10.00	None
NIFEDIPINE ER 60MG TABLET SA	2	Generic	$5.00	$10.00	None
NIFEDIPINE ER 90MG TABLET SA	2	Generic	$5.00	$10.00	None
NILANDRON 150MG TABLET	3	Preferred Brand	33%	33%	None
NIMODIPINE 30MG CAPSULE	2	Generic	$5.00	$10.00	None
NISOLDIPINE 20MG TB24	2	Generic	$5.00	$10.00	None
NISOLDIPINE 30MG TB24	2	Generic	$5.00	$10.00	None
NISOLDIPINE 40MG TB24	2	Generic	$5.00	$10.00	None
NITRO-DUR 0.3MG/HR PATCH	3	Preferred Brand	33%	33%	None
NITRO-DUR 0.8MG/HR PATCH INST.	3	Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROFURANTOIN 100MG CAPSULE (100 CT)	2	Generic	$5.00	$10.00	None
NITROFURANTOIN MCR 50MG CAP	2	Generic	$5.00	$10.00	None
NITROGLYCERIN .2MG/HR PATCH	2	Generic	$5.00	$10.00	None
NITROGLYCERIN .4MG/HR PATCH	2	Generic	$5.00	$10.00	None
NITROGLYCERIN .6MG/HR PATCH	2	Generic	$5.00	$10.00	None
NITROGLYCERIN 5MG/ML VIAL	2	Generic	$5.00	$10.00	P
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX	2	Generic	$5.00	$10.00	None
NITROLINGUAL SPR PUMPSPRA	3	Preferred Brand	33%	33%	None
NITROSTAT 0.3MG TABLET SL	3	Preferred Brand	33%	33%	None
NITROSTAT 0.4MG TABLET SL	3	Preferred Brand	33%	33%	None
NITROSTAT 0.6MG TABLET SL	3	Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORA-BE 0.35MG TABLET	2	Generic	$5.00	$10.00	None
NORDITROPIN 15MG/1.5ML CRTG	4	Specialty	33%	N/A	P
NORDITROPIN 5MG/1.5ML CRTG	4	Specialty	33%	N/A	P
NORDITROPIN NORDIFLEX 10MG/1.5	4	Specialty	33%	N/A	P
NORDITROPIN NORDIFLEX 15MG/1.5	4	Specialty	33%	N/A	P
NORDITROPIN NORDIFLEX 5MG/1.5	4	Specialty	33%	N/A	P
NORETHINDRONE 5MG TABLET	2	Generic	$5.00	$10.00	None
NORITATE 1% CREAM	3	Preferred Brand	33%	33%	None
NORMOSOL-R PH 7.4 IV SOLUTION	3	Preferred Brand	33%	33%	P
NORPACE CR 100MG CAPSULE SA	3	Preferred Brand	33%	33%	None
NORTREL .035-1MG TABLET 21DAY BLPK	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORTREL 0.035-0.5MG TABLET 28DAY BLPK	2	Generic	$5.00	$10.00	None
NORTREL 1-0.035MG TABLET 28DAY	2	Generic	$5.00	$10.00	None
NORTREL 7 DAYS X 3 TABLET	2	Generic	$5.00	$10.00	None
NORTRIPTYLINE 10MG/5ML SOL	2	Generic	$5.00	$10.00	None
NORTRIPTYLINE HCL 10MG CAPSULE	1	Value Generic	$2.50	$5.00	None
NORTRIPTYLINE HCL 25MG CAP	1	Value Generic	$2.50	$5.00	None
NORTRIPTYLINE HCL 50MG CAPSULE	1	Value Generic	$2.50	$5.00	None
NORTRIPTYLINE HCL 75MG CAPSULE	1	Value Generic	$2.50	$5.00	None
NORVIR 100MG SOFTGEL CAP	3	Preferred Brand	33%	33%	None
NORVIR 80MG/ML ORAL SOLUTION	3	Preferred Brand	33%	33%	None
NOVAMINE AMINO ACIDS INJECTION 15%	2	Generic	$5.00	$10.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOVAREL INJ 10000UNT	3	Preferred Brand	33%	33%	P
NOVOLIN 70/30 100U/ML VIAL	3	Preferred Brand	33%	33%	None
NOVOLIN 70/INJ 30 INNLT	3	Preferred Brand	33%	33%	None
NOVOLIN N 100U/ML VIAL	3	Preferred Brand	33%	33%	None
NOVOLIN N INJ INNOLET	3	Preferred Brand	33%	33%	None
NOVOLIN R 100U/ML VIAL	3	Preferred Brand	33%	33%	None
NOVOLIN R 100UNIT/ML INNOLET	3	Preferred Brand	33%	33%	None
NOVOLOG 100U/ML VIAL	3	Preferred Brand	33%	33%	None
NOVOLOG FLEXPEN SYRINGE	3	Preferred Brand	33%	33%	None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML	3	Preferred Brand	33%	33%	None
NOVOLOG MIX 70/30 VIAL	3	Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NUVARING 0.12-0.015 RING VAGINAL	3	Preferred Brand	33%	33%	None
NYAMYC 100000 U/G POWDER	2	Generic	$5.00	$10.00	None
NYSTATIN 100000U/G POWDER	2	Generic	$5.00	$10.00	None
NYSTATIN 100000U/GM CREAM	1	Value Generic	$2.50	$5.00	None
NYSTATIN OINTMENT 100000UNT/GM 15 GM TUBE	2	Generic	$5.00	$10.00	None
NYSTATIN ORAL SUSPENSION 100000U 473ML BOT	2	Generic	$5.00	$10.00	None
NYSTATIN TABLET 500000U (100 CT)	2	Generic	$5.00	$10.00	None
NYSTATIN/TRIAMCINOLONE CRM	2	Generic	$5.00	$10.00	None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG	2	Generic	$5.00	$10.00	None
NYSTOP 100000U/GM POWDER	2	Generic	$5.00	$10.00	None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D Advantage Freedom Plan by RxAmerica (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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2830) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing 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 2010 )

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.