2013 Medicare Part D Plan Formulary Information |
ODS Advantage PPORX Select (PPO) (H3813-003-0)
Benefit Details
|
The ODS Advantage PPORX Select (PPO) (H3813-003-0) Formulary Drugs Starting with the Letter N in JOSEPHINE County, OR: CMS MA Region 23 which includes: OR
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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 |
Preferred Generic |
$5.00 | $15.00 | None |
NABUMETONE 750MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NADOLOL 20MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NADOLOL TABLETS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NADOLOL TABLETS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NADOLOL-BENDROFLU 40-5 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NADOLOL-BENDROFLU 80-5 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nafcillin 10g/100mL |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NAFCILLIN 1GM/50ML INJ |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NAFCILLIN FOR INJECTION 1 GM/ML |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
30% | N/A | None |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
naloxone 1 mg/ml syringe |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NAMENDA 10MG TABLET |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:62 /31Days |
NAMENDA 10MG/5ML SOLUTION |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:360 /30Days |
NAMENDA 5-10MG TITRATION PK |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:49 /28Days |
NAMENDA 5MG TABLET |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:62 /31Days |
NAMENDA XR 14 MG CAPSULE |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /30Days |
NAMENDA XR 21 MG CAPSULE |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA XR 28 MG CAPSULE |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /30Days |
NAMENDA XR TITRATION PACK |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:28 /28Days |
NAPROXEN 125MG/5ML SUSPEN |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NAPROXEN 375MG TABLET EC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NAPROXEN 500MG TABLET EC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Naproxen Sodium 550mg/1 |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARATRIPTAN TABLETS |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | Q:18 /28Days |
NARATRIPTAN TABLETS |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | Q:18 /28Days |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:34 /28Days |
NATACYN EYE DROPS |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | Q:90 /30Days |
Nateglinide 60mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | Q:90 /30Days |
NECON 0.5/35-28 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NECON 1/35-28 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NECON 10/11-28 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NECON 7 DAYS X 3 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
NEFAZODONE HCL 50MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE in 1 CARTON / 1 mL in 1 AMPULE |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
3 |
Preferred Brand |
$41.00 | $123.00 | P |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
30% | N/A | None |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
30% | N/A | None |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
30% | N/A | None |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
30% | N/A | None |
NEUPRO 1 MG/24 HR PATCH |
3 |
Preferred Brand |
$41.00 | $123.00 | S Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH |
3 |
Preferred Brand |
$41.00 | $123.00 | S Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH |
3 |
Preferred Brand |
$41.00 | $123.00 | S Q:30 /30Days |
NEUPRO 4 MG/24 HR PATCH |
3 |
Preferred Brand |
$41.00 | $123.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 6 MG/24 HR PATCH |
3 |
Preferred Brand |
$41.00 | $123.00 | S Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH |
3 |
Preferred Brand |
$41.00 | $123.00 | S Q:30 /30Days |
NEVANAC 0.1% DROPTAINER |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
nevirapine 200 mg tablet |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
30% | N/A | P Q:120 /30Days |
NEXT CHOICE 0.75 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIACOR 500MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIASPAN 1000MG TABLET (90 CT) |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NIASPAN ER 500MG TABLET (90 CT) |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NIASPAN ER 750MG TABLET (90 CT) |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NICARDIPINE HYDROCHLORIDE 2.5mg/mL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NICARDIPINE HYDROCHLORIDE CAPSULES |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
4 |
Non-Preferred Brand |
50% | 50% | Q:2016 /365Days |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
4 |
Non-Preferred Brand |
50% | 50% | Q:240 /180Days |
NIFEDIAC CC 90MG TABLET SA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIFEDIPINE TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NILANDRON 150MG TABLET |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nimodipine 30mg/1 10 BLISTER PACK in 1 CARTON / 10 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NISOLDIPINE 20MG TB24 |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NISOLDIPINE 30MG TB24 |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NISOLDIPINE 40MG TB24 |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
Nitrofurantoin 25mg/5mL |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | P Q:600 /365Days |
NITROFURANTOIN MCR 50MG CAP |
1 |
Preferred Generic |
$5.00 | $15.00 | P Q:90 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | P Q:90 /365Days |
NITROGLYCERIN .2MG/HR PATCH |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days |
NITROGLYCERIN .4MG/HR PATCH |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:60 /30Days |
NITROGLYCERIN .6MG/HR PATCH |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NITROSTAT 0.4MG TABLET SL |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
Nizatidine 150mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIZATIDINE ORAL SOLUTION 15MG/ML |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | None |
NORA-BE 0.35MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
30% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
30% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
30% | N/A | P |
NORDITROPIN NORDIFLEX INJECTION |
5 |
Specialty Tier |
30% | N/A | P |
NORETHINDRONE 5MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NORMOSOL-M AND DEXTROSE 5% |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
3 |
Preferred Brand |
$41.00 | $123.00 | None |
NOROXIN 400mg/1 20 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | 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 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nortrel (28 Day Regimen) 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NORVIR 100 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
NORVIR 100mg/1 30 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
NORVIR 80MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
50% | 50% | None |
novarel 10,000 units vial |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Novolin 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:40 /28Days |
Novolin 100[USP'U]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:40 /28Days |
Novolin R 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:40 /28Days |
NOVOLOG 100U/ML VIAL |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:40 /28Days |
NOVOLOG FLEXPEN SYRINGE |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /28Days |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /28Days |
NOVOLOG MIX 70/30 VIAL |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:40 /28Days |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
30% | N/A | None |
NUCYNTA 100mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 FILM COATED TABLETS in BLISTER PACK |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:181 /30Days |
NUCYNTA 50mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 FILM COATED TABLETS in BLISTER PACK |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:181 /30Days |
NUCYNTA 75mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 FILM COATED TABLETS in BLISTER PACK |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:181 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:60 /30Days |
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:60 /30Days |
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:60 /30Days |
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:60 /30Days |
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:60 /30Days |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:60 /30Days |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier |
30% | N/A | P |
NUTROPIN 10 MG VIAL |
5 |
Specialty Tier |
30% | N/A | P |
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN |
5 |
Specialty Tier |
30% | N/A | P |
NUTROPIN AQ NUSPIN SOLUTION |
5 |
Specialty Tier |
30% | N/A | P |
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML |
5 |
Specialty Tier |
30% | N/A | P |
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 |
$41.00 | $123.00 | Q:1 /28Days |
NUVIGIL 150 MG ORAL TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P Q:30 /30Days |
NUVIGIL 250 MG ORAL TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P Q:30 /30Days |
NUVIGIL 50 MG ORAL TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P Q:90 /30Days |
NYAMYC 100000 U/G POWDER |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nystatin 100000[USP'U]/g |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Nystatin 100000[USP'U]/mL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
NYSTOP 100000U/GM POWDER |
1 |
Preferred Generic |
$5.00 | $15.00 | None |