2013 Medicare Part D Plan Formulary Information |
WellCare Access (HMO SNP) (H1112-006-0)
Benefit Details
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The WellCare Access (HMO SNP) (H1112-006-0) Formulary Drugs Starting with the Letter N in BARROW County, GA: CMS MA Region 8 which includes: GA
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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 |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NABUMETONE 750MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | 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 |
NAFTIN 1% CREAM |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAFTIN HCL GEL 1% 60GM TUBE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAGLAZYME 5MG/5ML VIAL |
4 |
Specialty Tier |
25% | N/A | P |
naloxone 1 mg/ml syringe |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA 10MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NAMENDA 10MG/5ML SOLUTION |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA 5-10MG TITRATION PK |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA 5MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NAMENDA XR 14 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:31 /31Days |
NAMENDA XR 21 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:31 /31Days |
NAMENDA XR 28 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:31 /31Days |
NAMENDA XR 7 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:31 /31Days |
NAMENDA XR TITRATION PACK |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAPROXEN 125MG/5ML SUSPEN |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAPROXEN 250 MG ORAL 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 |
Naproxen 500mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Naproxen Sodium 550mg/1 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NARATRIPTAN TABLETS |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:9 /31Days |
NARATRIPTAN TABLETS |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:9 /31Days |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NATACYN EYE DROPS |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Nateglinide 60mg/1 90 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NECON 0.5/35-28 TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NECON 1/35-28 TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NECON 10/11-28 TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NECON 7 DAYS X 3 TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEFAZODONE HCL 250MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEFAZODONE HCL 50MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE in 1 CARTON / 1 mL in 1 AMPULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEUPOGEN 300MCG/ML VIAL |
4 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
4 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
4 |
Specialty Tier |
25% | N/A | P |
NEVANAC 0.1% DROPTAINER |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
nevirapine 200 mg tablet |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
4 |
Specialty Tier |
25% | N/A | P Q:124 /31Days |
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE in 1 CARTON |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXIUM 20MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXIUM 40MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXIUM DR 2.5 MG PACKET |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXIUM DR 5 MG PACKET |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NEXT CHOICE 0.75 MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NIACOR 500MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIASPAN 1000MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NIASPAN ER 500MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NIASPAN ER 750MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NIFEDIAC CC 90MG TABLET SA |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
Nifedipine 10mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NIFEDIPINE 20MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDIPINE TABLETS EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NIFEDIPINE TABLETS EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NIFEDIPINE TABLETS EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:62 /31Days |
NILANDRON 150MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Nimodipine 30mg/1 10 BLISTER PACK in 1 CARTON / 10 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NITROFURANTOIN MCR 50MG CAP |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NITROGLYCERIN .2MG/HR PATCH |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
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 |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NITROSTAT 0.3MG TABLET SL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NITROSTAT 0.4MG TABLET SL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NITROSTAT 0.6MG TABLET SL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORA-BE 0.35MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORMOSOL -R INJ /D5W |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORMOSOL-M AND DEXTROSE 5% |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORPACE CR 100MG CAPSULE SA |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORPACE CR 150MG CAPSULE SA |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 21 TABLET in 1 BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
2 |
Preferred Brand |
$45.00 | $90.00 | 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 |
$45.00 | $90.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
NORVIR 100 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NORVIR 100mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
4 |
Specialty Tier |
25% | N/A | P |
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
NYAMYC 100000 U/G POWDER |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/mL |
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 |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
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 |
NYSTOP 100000U/GM POWDER |
1* |
Preferred Generic |
$0.00 | $0.00 | None |