2012 Medicare Part D Plan Formulary Information |
Health Net Orange Option 2 (PDP) (S5678-012-0)
Sanctioned Plan
|
The Health Net Orange Option 2 (PDP) (S5678-012-0) 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 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NABUMETONE 750MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NADOLOL 20MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nadolol and Bendroflumethiazide 5; 40mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nadolol and Bendroflumethiazide 5; 80mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NADOLOL TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NADOLOL TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nafcillin 10g/100mL |
4 |
Injectable Drugs |
33% | 33% | None |
NAFCILLIN 1GM/50ML INJ |
4 |
Injectable Drugs |
33% | 33% | None |
NAFCILLIN FOR INJECTION 1 GM/ML |
4 |
Injectable Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAFTIN 1% CREAM |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAFTIN HCL GEL 1% 60GM TUBE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Injectable Drugs |
33% | 33% | None |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Injectable Drugs |
33% | 33% | None |
NALFON 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NALOXONE 1MG/ML SYRINGE |
4 |
Injectable Drugs |
33% | 33% | None |
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG |
4 |
Injectable Drugs |
33% | 33% | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NAMENDA 10MG TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NAMENDA 10MG/5ML SOLUTION |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA 5-10MG TITRATION PK |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NAMENDA 5MG TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NAPRELAN 375MG TABLET SA |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NAPRELAN CONTROLLED RELEASE TABLETS 750MG 30 TAB BOT |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAPRELAN CR 500MG TABLET 75 BOT |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NAPROSYN 125MG/5ML ORAL SUSP |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAPROSYN 250MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAPROSYN 375MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAPROSYN 500MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAPROXEN 125MG/5ML SUSPEN |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 375MG TABLET EC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NAPROXEN 500MG TABLET EC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Naproxen 500mg/1 500 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Naproxen Sodium 550mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NARATRIPTAN TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NARATRIPTAN TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NARDIL 15MG TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NASACORT AQ AER 55MCG/AC |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NATACYN EYE DROPS |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
Nateglinide 120mg/1 90 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nateglinide 60mg/1 90 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NAVANE 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NAVANE 2MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NEBUPENT 300MG INHAL POWDER |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | P |
NECON 0.5/35-28 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NECON 1/35-28 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NECON 10/11-28 TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NECON 7 DAYS X 3 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEFAZODONE HCL 250MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEFAZODONE HCL 50MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE in 1 CARTON / 1 mL in 1 AMPULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEORAL 100MG GELATN CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | P |
NEORAL 100MG/ML SOLUTION |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | P |
NEORAL 25MG GELATIN CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | P |
NEOSPORIN EYE DROPS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Injectable Drugs |
33% | 33% | P |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier Drugs |
33% | 33% | P |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier Drugs |
33% | 33% | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEURONTIN 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NEURONTIN 250MG/5ML TUBEX |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NEURONTIN 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NEURONTIN 400MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NEURONTIN 600MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NEURONTIN 800MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NEVANAC 0.1% DROPTAINER |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
nevirapine 200 mg tablet |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier Drugs |
33% | 33% | None |
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | S |
NEXIUM 20MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | S |
NEXIUM 40MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | S |
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | S |
NEXIUM IV 20MG VIAL |
4 |
Injectable Drugs |
33% | 33% | None |
NEXIUM IV 40MG VIAL |
4 |
Injectable Drugs |
33% | 33% | None |
NEXT CHOICE 0.75 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIACOR 500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIASPAN 1000MG TABLET (90 CT) |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NIASPAN ER 500MG TABLET (90 CT) |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NIASPAN ER 750MG TABLET (90 CT) |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NICARDIPINE HYDROCHLORIDE 2.5mg/mL |
4 |
Injectable Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NICARDIPINE HYDROCHLORIDE CAPSULES |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NIFEDIAC CC 30MG TABLET SA |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDIAC CC 60MG TABLET SA |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDIAC CC 90MG TABLET SA |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nifedipine 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDIPINE 20MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NILANDRON 150MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NIMODIPINE 30MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIPENT FOR INJECTION 10MG VIALS |
4 |
Injectable Drugs |
33% | 33% | None |
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITRO-DUR 0.1MG/HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NITRO-DUR 0.3MG/HR PATCH |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NITRO-DUR 0.6MG 30 BOX |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NITRO-DUR 0.8MG/HR PATCH INST. |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NITRO-DUR NITROGLYCERIN 0.4MG/HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NITRO-DUR PATCHES 0.2MG 30 BOX |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
Nitrofurantoin 25mg/5mL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NITROFURANTOIN MCR 50MG CAP |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NITROGLYCERIN .2MG/HR PATCH |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN .6MG/HR PATCH |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
4 |
Injectable Drugs |
33% | 33% | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nitrolingual Pumpspray 400ug/1 200 SPRAY, METERED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NITROMIST AEROSOL |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NITROSTAT 0.3MG TABLET SL |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NITROSTAT 0.4MG TABLET SL |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NITROSTAT 0.6MG TABLET SL |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NIZATIDINE 150MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NIZATIDINE ORAL SOLUTION 15MG/ML |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nizoral 20mg/mL 120 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOR-QD TABLET 0.35MG |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORA-BE 0.35MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORCO 10/325 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORCO 5-325 TABLET (100 TABS) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORCO 7.5/325 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nordette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
4 |
Injectable Drugs |
33% | 33% | None |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
4 |
Injectable Drugs |
33% | 33% | None |
NORDITROPIN NORDIFLEX INJECTION |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORETHINDRONE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORINYL 1+35-28 TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORITATE 1% CREAM |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORMOSOL -R INJ /D5W |
4 |
Injectable Drugs |
33% | 33% | None |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Injectable Drugs |
33% | 33% | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Injectable Drugs |
33% | 33% | None |
NOROXIN 400mg/1 20 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPACE 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPACE 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPACE CR 100MG CAPSULE SA |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NORPACE CR 150MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORPRAMIN 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPRAMIN 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPRAMIN 150MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPRAMIN 25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPRAMIN 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORPRAMIN 75MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 21 TABLET in 1 BLISTER PACK |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORTRIPTYLINE 10MG/5ML SOL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NORVASC 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORVASC 2.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORVASC 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORVIR 100 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORVIR 100mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOVANTRONE 2MG/ML VIAL |
4 |
Injectable Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NOVAREL INJ 10000UNT |
4 |
Injectable Drugs |
33% | 33% | None |
Novolin 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
Novolin 100[USP'U]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
Novolin R 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOVOLOG 100U/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOVOLOG FLEXPEN SYRINGE |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOVOLOG MIX 70/30 VIAL |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier Drugs |
33% | 33% | None |
NUCYNTA 100mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET, FILM COATED in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUCYNTA 50mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET, FILM COATED in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUCYNTA 75mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET, FILM COATED in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUEDEXTA 20; 10mg/1; mg/1 |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier Drugs |
33% | 33% | P |
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT |
3 |
Non-Preferred Brand Drugs |
$75.00 | $188.00 | None |
NUTROPIN 10 MG VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | None |
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML |
5 |
Specialty Tier Drugs |
33% | 33% | None |
NUVARING 0.12-0.015 RING VAGINAL |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | None |
NUVIGIL 150 MG ORAL TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | P |
NUVIGIL 250 MG ORAL TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | P |
NUVIGIL 50 MG ORAL TABLET |
2 |
Preferred Brand Drugs |
$38.00 | $76.00 | P |
NYAMYC 100000 U/G POWDER |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/mL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN/TRIAMCINOLONE CRM |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
NYSTOP 100000U/GM POWDER |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |