2011 Medicare Part D Plan Formulary Information |
First Health Part D Premier Plus (PDP) (S5674-023-0)
Benefit Details
|
The First Health Part D Premier Plus (PDP) (S5674-023-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 11 which includes: FL
|
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 |
2 |
Generic |
$25.00 | $62.50 | None |
NABUMETONE 750MG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
NADOLOL 20MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NADOLOL TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NADOLOL TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NADOLOL-BENDROFLUMETHIAZIDE 40-5MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NADOLOL-BENDROFLUMETHIAZIDE 80-5MG TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NAFAZAIR 0.1% EYE DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAFCILLIN FOR INJECTION 1 GM/ML |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NAFCILLIN FOR INJECTION 10GM/ML 1 VIAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAFTIN HCL GEL 1% 60GM TUBE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:40 /30Days |
NAFTIN 1% CREAM |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
NALBUPHINE 10MG/ML VIAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NALBUPHINE 20MG/ML VIAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NALFON 200MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NALOXONE 1MG/ML SYRINGE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
2 |
Generic |
$25.00 | $62.50 | None |
NAMENDA 10MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:60 /30Days |
NAMENDA 10MG/5ML SOLUTION |
3 |
Preferred Brand |
30% | 27% | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA 5-10MG TITRATION PK |
3 |
Preferred Brand |
30% | 27% | Q:49 /28Days |
NAMENDA 5MG TABLET |
3 |
Preferred Brand |
30% | 27% | Q:60 /30Days |
NAPROXEN 125MG/5ML SUSPEN |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN 375MG TABLET EC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN 500MG TABLET EC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN SODIUM 550 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NARATRIPTAN TABLETS |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:9 /30Days |
NARATRIPTAN TABLETS |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | S Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARDIL 15MG TABLET |
3 |
Preferred Brand |
30% | 27% | None |
NASACORT AQ AER 55MCG/AC |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:33 /30Days |
NASONEX 50MCG NASAL SPRAY |
3 |
Preferred Brand |
30% | 27% | Q:34 /30Days |
NATACYN EYE DROPS |
3 |
Preferred Brand |
30% | 27% | None |
NATEGLINIDE 120 MG ORAL TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:90 /30Days |
NATEGLINIDE 60 MG ORAL TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:90 /30Days |
NAVANE 20MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
30% | 27% | P |
NECON 0.5/35-28 TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NECON 1/35-28 TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NECON 10/11-28 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NECON 7 DAYS X 3 TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEFAZODONE HCL 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEFAZODONE HCL 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEO-FRADIN 125MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEOMYCIN AND POLYMYXIN B SULFATES AND DEXAMETHASONE OPHTHALMIC OINTMENT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Generic |
$25.00 | $62.50 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NEORAL 100MG GELATN CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
NEORAL 100MG/ML SOLUTION |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
NEORAL 25MG GELATIN CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
NEUPOGEN INJECTION 300MCG/0.5ML 0.5ML SYR |
5 |
Specialty Tier |
33% | N/A | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEURONTIN 250MG/5ML TUBEX |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NEVANAC 0.1% DROPTAINER |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:3 /30Days |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
NEXIUM 10MG PACKET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
NEXIUM 20MG CAPSULE |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
NEXIUM 40MG CAPSULE |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
NEXIUM IV 20MG VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NEXIUM IV 40MG VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NEXT CHOICE 0.75 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIACOR 500MG TABLET |
3 |
Preferred Brand |
30% | 27% | None |
NIASPAN 1000MG TABLET (90 CT) |
3 |
Preferred Brand |
30% | 27% | Q:60 /30Days |
NIASPAN ER 500MG TABLET (90 CT) |
3 |
Preferred Brand |
30% | 27% | Q:30 /30Days |
NIASPAN ER 750MG TABLET (90 CT) |
3 |
Preferred Brand |
30% | 27% | Q:60 /30Days |
NICARDIPINE HYDROCHLORIDE CAPSULES |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
30% | 27% | Q:40 /30Days |
NIFEDIAC CC 30MG TABLET SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NIFEDIAC CC 60MG TABLET SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NIFEDIAC CC 90MG TABLET SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
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 |
Preferred Generic |
$0.00 | $0.00 | None |
NIFEDIPINE 10MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NIFEDIPINE 20MG CAPSULE |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NILANDRON 150MG TABLET |
3 |
Preferred Brand |
30% | 27% | None |
NIMODIPINE 30MG CAPSULE |
2 |
Generic |
$25.00 | $62.50 | None |
NISOLDIPINE 20MG TB24 |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
NISOLDIPINE 30MG TB24 |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:60 /30Days |
NISOLDIPINE 40MG TB24 |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITRO BID OINTMENT 2% 1 GRAM X 48 PKG |
3 |
Preferred Brand |
30% | 27% | None |
NITRO-DUR 0.1MG/HR PATCH TRANSDERMAL 24 HOURS |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
NITRO-DUR 0.3MG/HR PATCH |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
NITRO-DUR 0.6MG 30 BOX |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
NITRO-DUR 0.8MG/HR PATCH INST. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
NITRO-DUR NITROGLYCERIN 0.4MG/HR PATCH TRANSDERMAL 24 HOURS |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
NITRO-DUR PATCHES 0.2MG 30 BOX |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
NITROFURANTOIN 100MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NITROFURANTOIN MCR 50MG CAP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NITROGLYCERIN 5MG/ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NITROLINGUAL SPR PUMPSPRA |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
30% | 27% | None |
NITROSTAT 0.4MG TABLET SL |
3 |
Preferred Brand |
30% | 27% | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
30% | 27% | None |
NIZATIDINE 150MG CAPSULE |
2 |
Generic |
$25.00 | $62.50 | None |
NIZATIDINE 300MG CAPSULE |
2 |
Generic |
$25.00 | $62.50 | None |
NIZATIDINE ORAL SOLUTION 15MG/ML |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NORA-BE 0.35MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NORDITROPIN NORDIFLEX 10MG/1.5 |
5 |
Specialty Tier |
33% | N/A | P |
NORDITROPIN NORDIFLEX INJECTION |
5 |
Specialty Tier |
33% | N/A | P |
NORDITROPIN NORDIFLEX INJECTION |
5 |
Specialty Tier |
33% | N/A | P |
NORDITROPIN NORDIFLEX INJECTION |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORETHINDRONE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NORITATE 1% CREAM |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NORPACE CR 100MG CAPSULE SA |
3 |
Preferred Brand |
30% | 27% | None |
NORPACE CR 150MG CAPSULE SA |
3 |
Preferred Brand |
30% | 27% | None |
NORTREL 0.5-0.035 TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NORTREL 1-0.035MG TABLET 21DAY |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NORTREL 1-0.035MG TABLET 28DAY |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NORTREL 7 DAYS X 3 TABLET |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | None |
NORTRIPTYLINE 10MG/5ML SOL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 10MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTRIPTYLINE HCL 50MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NORVIR 100 MG TABLET |
3 |
Preferred Brand |
30% | 27% | None |
NORVIR 100MG SOFTGEL CAP |
3 |
Preferred Brand |
30% | 27% | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
30% | 27% | None |
NOVAMINE 15% 500ML IV |
4 |
Non-Preferred Generic and Non-Preferred Brand |
60% | 60% | P |
NOVOLIN 70/30 100U/ML VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NOVOLIN N 100U/ML VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NOVOLIN R 100U/ML VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NOVOLOG 100U/ML VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NOVOLOG FLEXPEN SYRINGE |
3 |
Preferred Brand |
30% | 27% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
3 |
Preferred Brand |
30% | 27% | P |
NOVOLOG MIX 70/30 VIAL |
3 |
Preferred Brand |
30% | 27% | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
33% | N/A | P Q:630 /30Days |
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT |
3 |
Preferred Brand |
30% | 27% | None |
NYAMYC 100000 U/G POWDER |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTATIN 100000 UNT/ML ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTATIN 100000U/G POWDER |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTATIN 100000U/GM CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTATIN OINTMENT 100000UNT/GM 15 GM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
NYSTOP 100000U/GM POWDER |
1 |
Preferred Generic |
$0.00 | $0.00 | None |