2012 Medicare Part D Plan Formulary Information |
PICA Primero (PDP) (S5775-001-0)
Benefit Details
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The PICA Primero (PDP) (S5775-001-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 38 which includes: PR
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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 Drugs |
$2.00 | $6.00 | None |
NABUMETONE 750MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NADOLOL 20MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NADOLOL TABLETS |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NADOLOL TABLETS |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NAFCILLIN FOR INJECTION 1 GM/ML |
1 |
Generic Drugs |
$2.00 | $6.00 | P |
NAGLAZYME 5MG/5ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NALOXONE 1MG/ML SYRINGE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NAMENDA 10MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NAMENDA 10MG/5ML SOLUTION |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NAMENDA 5-10MG TITRATION PK |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NAMENDA 5MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NAPRELAN 375MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NAPRELAN CR 500MG TABLET 75 BOT |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NAPROXEN 125MG/5ML SUSPEN |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NAPROXEN 375MG TABLET EC |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 500MG TABLET EC |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Naproxen 500mg/1 500 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Naproxen Sodium 550mg/1 |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NARDIL 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NASACORT AQ AER 55MCG/AC |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NATACYN EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Nateglinide 120mg/1 90 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nateglinide 60mg/1 90 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAVANE 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NAVANE 2MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NEBUPENT 300MG INHAL POWDER |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | P |
NECON 7 DAYS X 3 TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEFAZODONE HCL 250MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEFAZODONE HCL 50MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN SULFATE 500MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEOSPORIN EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NEUPOGEN 300MCG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P Q:15 /15Days |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
4 |
Specialty Tier Drugs |
33% | 33% | P Q:15 /15Days |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
4 |
Specialty Tier Drugs |
33% | 33% | P Q:15 /15Days |
NEVANAC 0.1% DROPTAINER |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | Q:3 /15Days |
nevirapine 200 mg tablet |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
4 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE in 1 CARTON |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NEXIUM 20MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NEXIUM 40MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NIACOR 500MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIASPAN 1000MG TABLET (90 CT) |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:60 /30Days |
NIASPAN ER 500MG TABLET (90 CT) |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:120 /30Days |
NIASPAN ER 750MG TABLET (90 CT) |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:120 /30Days |
NICARDIPINE HYDROCHLORIDE CAPSULES |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NIFEDIAC CC 30MG TABLET SA |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDIAC CC 60MG TABLET SA |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDIAC CC 90MG TABLET SA |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NILANDRON 150MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NITRO-DUR 0.1MG/HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:30 /30Days |
NITRO-DUR 0.3MG/HR PATCH |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NITRO-DUR 0.6MG 30 BOX |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:30 /30Days |
NITRO-DUR 0.8MG/HR PATCH INST. |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NITRO-DUR NITROGLYCERIN 0.4MG/HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:30 /30Days |
NITRO-DUR PATCHES 0.2MG 30 BOX |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | Q:30 /30Days |
Nitrofurantoin 25mg/5mL |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NITROFURANTOIN MCR 50MG CAP |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NITROGLYCERIN .2MG/HR PATCH |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN .4MG/HR PATCH |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nitrolingual Pumpspray 400ug/1 200 SPRAY, METERED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NITROSTAT 0.3MG TABLET SL |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NITROSTAT 0.4MG TABLET SL |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NITROSTAT 0.6MG TABLET SL |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIZATIDINE 150MG CAPSULE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nizoral 20mg/mL 120 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORCO 10/325 TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORCO 5-325 TABLET (100 TABS) |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORCO 7.5/325 TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORETHINDRONE 5MG TABLET |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NORPACE 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPACE CR 100MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPACE CR 150MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPRAMIN 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPRAMIN 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPRAMIN 150MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPRAMIN 25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORPRAMIN 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORPRAMIN 75MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NORTRIPTYLINE 10MG/5ML SOL |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NORVASC 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORVASC 2.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORVASC 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 100 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORVIR 100mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand Drugs |
$50.00 | $150.00 | None |
NOVANTRONE 2MG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | None |
Novolin 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
Novolin 100[USP'U]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
Novolin R 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NOVOLOG 100U/ML VIAL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NOVOLOG FLEXPEN SYRINGE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
NOVOLOG MIX 70/30 VIAL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
4 |
Specialty Tier Drugs |
33% | 33% | P |
Nystatin 100000[USP'U]/g |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
Nystatin 100000[USP'U]/mL |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
1 |
Generic Drugs |
$2.00 | $6.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
1 |
Generic Drugs |
$2.00 | $6.00 | None |