Q1Medicare.com 2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

2014 Medicare Part D Plan Formulary Information
Stride (HMO) (H1660-005-0) Benefit Details
The Stride (HMO) (H1660-005-0) Formulary Drugs Starting with the Letter N in CUMBERLAND County, ME: CMS MA Region 1 which includes: ME Plan Monthly Premium: $53.00 Deductible: $0
Drugs Starting with Letter N Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter N Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NABUMETONE 500MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NABUMETONE 750MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NADOLOL 20MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NADOLOL 40MG TABLETS	2	Non-Preferred Generic	$10.00	$27.00	None
NADOLOL 80MG TABLETS	2	Non-Preferred Generic	$10.00	$27.00	None
NADOLOL-BENDROFLU 40-5 MG TAB	2	Non-Preferred Generic	$10.00	$27.00	None
NADOLOL-BENDROFLU 80-5 MG TAB	2	Non-Preferred Generic	$10.00	$27.00	None
Nafcillin 10g/100mL	2	Non-Preferred Generic	$10.00	$27.00	None
NAFCILLIN 1GM/50ML INJ	4	Non-Preferred Brand	40%	40%	None
NAFCILLIN FOR INJECTION 1 GM/ML	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAFTIN 1% CREAM	4	Non-Preferred Brand	40%	40%	None
NAFTIN 2% CREAM	4	Non-Preferred Brand	40%	40%	None
NAFTIN 2% GEL	4	Non-Preferred Brand	40%	40%	None
NAFTIN HCL GEL 1% 60GM TUBE	4	Non-Preferred Brand	40%	40%	None
NAGLAZYME 5MG/5ML VIAL	4	Non-Preferred Brand	40%	40%	P
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	2	Non-Preferred Generic	$10.00	$27.00	None
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	2	Non-Preferred Generic	$10.00	$27.00	None
NALFON 400 MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
naloxone 1 mg/ml syringe	2	Non-Preferred Generic	$10.00	$27.00	None
NALTREXONE HCL 50MG TABLET 100 BLPK	2	Non-Preferred Generic	$10.00	$27.00	None
NAMENDA 10MG TABLET	3	Preferred Brand	25%	25%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAMENDA 10MG/5ML SOLUTION	3	Preferred Brand	25%	25%	None
NAMENDA 5-10MG TITRATION PK	3	Preferred Brand	25%	25%	None
NAMENDA 5MG TABLET	3	Preferred Brand	25%	25%	None
NAMENDA XR 14 MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NAMENDA XR 21 MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NAMENDA XR 28 MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NAMENDA XR 7 MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NAMENDA XR TITRATION PACK	4	Non-Preferred Brand	40%	40%	None
NAPRELAN CR 375 MG TABLET	4	Non-Preferred Brand	40%	40%	None
NAPRELAN CR 500 MG TABLET	4	Non-Preferred Brand	40%	40%	None
NAPRELAN CR 750 MG TABLET	4	Non-Preferred Brand	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROSYN 125MG/5ML ORAL SUSP	4	Non-Preferred Brand	40%	40%	None
NAPROSYN 250MG TABLET	4	Non-Preferred Brand	40%	40%	None
NAPROSYN 375MG TABLET	4	Non-Preferred Brand	40%	40%	None
NAPROSYN 500MG TABLET	4	Non-Preferred Brand	40%	40%	None
NAPROXEN 125 MG/5 ML SUSPEN	2	Non-Preferred Generic	$10.00	$27.00	None
NAPROXEN 250 MG ORAL TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NAPROXEN 375MG TABLET EC	2	Non-Preferred Generic	$10.00	$27.00	None
NAPROXEN 500MG TABLET EC	2	Non-Preferred Generic	$10.00	$27.00	None
Naproxen 500mg/1 500 TABLET BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
NAPROXEN SODIUM 275 MG ORAL TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
Naproxen Sodium 550mg/1	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROXEN TABLET 375MG (500 CT)	2	Non-Preferred Generic	$10.00	$27.00	None
NARATRIPTAN 1MG TABLETS	2	Non-Preferred Generic	$10.00	$27.00	Q:15 /1Days
NARATRIPTAN 2.5MG TABLETS	2	Non-Preferred Generic	$10.00	$27.00	Q:6 /1Days
NARDIL 15MG TABLET	4	Non-Preferred Brand	40%	40%	None
NASACORT AQ AER 55MCG/AC	4	Non-Preferred Brand	40%	40%	None
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP	3	Preferred Brand	25%	25%	None
NATACYN EYE DROPS	3	Preferred Brand	25%	25%	None
Natazia 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	40%	40%	None
Nateglinide 120mg/1 90 TABLET BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
Nateglinide 60mg/1 90 TABLET BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
NEBUPENT 300MG INHAL POWDER	3	Preferred Brand	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NECON 0.5/35-28 TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NECON 1/35-28 TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NECON 10/11-28 TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NECON 7 DAYS X 3 TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NEFAZODONE HCL 150MG TABLET (60 CT)	2	Non-Preferred Generic	$10.00	$27.00	None
NEFAZODONE HCL 250MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NEFAZODONE HCL 50MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT	2	Non-Preferred Generic	$10.00	$27.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT	2	Non-Preferred Generic	$10.00	$27.00	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	2	Non-Preferred Generic	$10.00	$27.00	None
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1	1	Preferred Generic	$3.00	$7.50	None
NEOMYCIN SULFATE 500MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT	2	Non-Preferred Generic	$10.00	$27.00	None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS	2	Non-Preferred Generic	$10.00	$27.00	None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML	1	Preferred Generic	$3.00	$7.50	None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M	2	Non-Preferred Generic	$10.00	$27.00	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	2	Non-Preferred Generic	$10.00	$27.00	None
NEORAL 100MG GELATN CAPSULE	4	Non-Preferred Brand	40%	40%	P
NEORAL 100MG/ML SOLUTION	4	Non-Preferred Brand	40%	40%	P
NEORAL 25MG GELATIN CAPSULE	4	Non-Preferred Brand	40%	40%	P
NEOSPORIN EYE DROPS	4	Non-Preferred Brand	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEPHRAMINE SOLUTION FOR INJECTION	4	Non-Preferred Brand	40%	40%	P
NESINA 12.5 MG TABLET	4	Non-Preferred Brand	40%	40%	S
NESINA 25 MG TABLET	4	Non-Preferred Brand	40%	40%	S
NESINA 6.25 MG TABLET	4	Non-Preferred Brand	40%	40%	S
NEULASTA 6MG/0.6ML SYRINGE	3	Preferred Brand	25%	25%	None
NEUPOGEN 300MCG/ML VIAL	3	Preferred Brand	25%	25%	None
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE	4	Non-Preferred Brand	40%	40%	None
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR	4	Non-Preferred Brand	40%	40%	None
NEUPRO 1 MG/24 HR PATCH	3	Preferred Brand	25%	25%	None
NEUPRO 2 MG/24 HR PATCH	3	Preferred Brand	25%	25%	None
NEUPRO 3 MG/24 HR PATCH	3	Preferred Brand	25%	25%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEUPRO 4 MG/24 HR PATCH	3	Preferred Brand	25%	25%	None
NEUPRO 6 MG/24 HR PATCH	3	Preferred Brand	25%	25%	None
NEUPRO 8 MG/24 HR PATCH	3	Preferred Brand	25%	25%	None
NEURONTIN 100MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NEURONTIN 250MG/5ML TUBEX	4	Non-Preferred Brand	40%	40%	None
NEURONTIN 300MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NEURONTIN 400MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NEURONTIN 600MG TABLET	4	Non-Preferred Brand	40%	40%	None
NEURONTIN 800MG TABLET	4	Non-Preferred Brand	40%	40%	None
NEVANAC 0.1% DROPTAINER	3	Preferred Brand	25%	25%	None
nevirapine 200 mg tablet	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
nevirapine er 400 mg tablet	2	Non-Preferred Generic	$10.00	$27.00	None
NEXAVAR TABLETS 200MG 120 BOT	4	Non-Preferred Brand	40%	40%	None
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE per CARTON	3	Preferred Brand	25%	25%	None
NEXIUM 20MG CAPSULE	3	Preferred Brand	25%	25%	None
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	25%	25%	None
NEXIUM 40MG CAPSULE	3	Preferred Brand	25%	25%	None
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	25%	25%	None
NEXIUM DR 2.5 MG PACKET	3	Preferred Brand	25%	25%	None
NEXIUM DR 5 MG PACKET	3	Preferred Brand	25%	25%	None
NEXIUM IV 20MG VIAL	3	Preferred Brand	25%	25%	None
NEXIUM IV 40MG VIAL	3	Preferred Brand	25%	25%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nexterone 150mg/100mL 100 mL in 1 BAG	4	Non-Preferred Brand	40%	40%	None
Nexterone 360mg/200mL 200 mL in 1 BAG	4	Non-Preferred Brand	40%	40%	None
NIACIN ER 1,000 MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NIACIN ER 500 MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NIACIN ER 750 MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NIACOR 500MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NIASPAN 1000MG TABLET (90 CT)	3	Preferred Brand	25%	25%	None
NIASPAN ER 500MG TABLET (90 CT)	3	Preferred Brand	25%	25%	None
NIASPAN ER 750MG TABLET (90 CT)	3	Preferred Brand	25%	25%	None
Nicardipine 25 mg/10 ml vial	2	Non-Preferred Generic	$10.00	$27.00	None
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT	2	Non-Preferred Generic	$10.00	$27.00	None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL	4	Non-Preferred Brand	40%	40%	Q:2000 /365Days
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL	4	Non-Preferred Brand	40%	40%	Q:400 /365Days
NIFEDIAC CC 90MG TABLET SA	2	Non-Preferred Generic	$10.00	$27.00	None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR	2	Non-Preferred Generic	$10.00	$27.00	None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR	2	Non-Preferred Generic	$10.00	$27.00	None
Nifedipine 10mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
NIFEDIPINE 20MG CAPSULE	2	Non-Preferred Generic	$10.00	$27.00	None
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE	2	Non-Preferred Generic	$10.00	$27.00	None
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE	2	Non-Preferred Generic	$10.00	$27.00	None
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NILANDRON 150 MG TABLET	3	Preferred Brand	25%	25%	None
nimodipine 30 mg capsule	2	Non-Preferred Generic	$10.00	$27.00	None
NIPENT FOR INJECTION 10MG VIALS	4	Non-Preferred Brand	40%	40%	None
Niravam 0.25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE	4	Non-Preferred Brand	40%	40%	None
Niravam 0.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE	4	Non-Preferred Brand	40%	40%	None
Niravam 1mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE	4	Non-Preferred Brand	40%	40%	None
Niravam 2mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE	4	Non-Preferred Brand	40%	40%	None
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$10.00	$27.00	None
NISOLDIPINE 20MG TB24	2	Non-Preferred Generic	$10.00	$27.00	None
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$10.00	$27.00	None
NISOLDIPINE 30MG TB24	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$10.00	$27.00	None
NISOLDIPINE 40MG TB24	2	Non-Preferred Generic	$10.00	$27.00	None
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$10.00	$27.00	None
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET	3	Preferred Brand	25%	25%	None
NITRO-DUR 0.1 MG/HR PATCH	4	Non-Preferred Brand	40%	40%	None
NITRO-DUR 0.2 MG/HR PATCH	4	Non-Preferred Brand	40%	40%	None
NITRO-DUR 0.3 MG/HR PATCH	4	Non-Preferred Brand	40%	40%	None
NITRO-DUR 0.4 MG/HR PATCH	4	Non-Preferred Brand	40%	40%	None
NITRO-DUR 0.6 MG/HR PATCH	4	Non-Preferred Brand	40%	40%	None
NITRO-DUR 0.8 MG/HR PATCH	4	Non-Preferred Brand	40%	40%	None
Nitrofurantoin 25mg/5mL	2	Non-Preferred Generic	$10.00	$27.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROFURANTOIN MCR 50MG CAP	2	Non-Preferred Generic	$10.00	$27.00	None
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
NITROGLYCERIN .2MG/HR PATCH	2	Non-Preferred Generic	$10.00	$27.00	None
NITROGLYCERIN .4MG/HR PATCH	2	Non-Preferred Generic	$10.00	$27.00	None
NITROGLYCERIN .6MG/HR PATCH	2	Non-Preferred Generic	$10.00	$27.00	None
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE	2	Non-Preferred Generic	$10.00	$27.00	None
NITROGLYCERIN LINGUAL 0.4 MG	2	Non-Preferred Generic	$10.00	$27.00	None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX	2	Non-Preferred Generic	$10.00	$27.00	None
Nitrolingual Pumpspray 400ug/1 200 SPRAY, METERED in 1 BOTTLE	4	Non-Preferred Brand	40%	40%	None
NITROMIST AEROSOL	4	Non-Preferred Brand	40%	40%	None
NITROSTAT 0.3MG TABLET SL	3	Preferred Brand	25%	25%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROSTAT 0.4MG TABLET SL	3	Preferred Brand	25%	25%	None
NITROSTAT 0.6MG TABLET SL	3	Preferred Brand	25%	25%	None
Nizatidine 150mg/1 500 CAPSULE BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
NIZATIDINE 300 MG CAPSULE (100 CAPS)	2	Non-Preferred Generic	$10.00	$27.00	None
NIZATIDINE ORAL SOLUTION 15MG/ML	2	Non-Preferred Generic	$10.00	$27.00	None
Nizoral 20mg/mL 120 mL in 1 BOTTLE	4	Non-Preferred Brand	40%	40%	None
NOR-QD TABLET 0.35MG	4	Non-Preferred Brand	40%	40%	None
NORA-BE 0.35MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NORCO 10-325 TABLET	4	Non-Preferred Brand	40%	40%	Q:360 /30Days
NORCO 5-325 TABLET (100 TABS)	4	Non-Preferred Brand	40%	40%	Q:360 /30Days
NORCO 7.5-325 TABLET	4	Non-Preferred Brand	40%	40%	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	40%	40%	None
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	40%	40%	None
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	40%	40%	None
NORDITROPIN NORDIFLEX 30MG/3ML INJECTION	4	Non-Preferred Brand	40%	40%	None
Norethindrone 0.35 mg tablet	2	Non-Preferred Generic	$10.00	$27.00	None
NORETHINDRONE 5MG TABLET	2	Non-Preferred Generic	$10.00	$27.00	None
NORINYL 1+35-28 TABLET 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	40%	40%	None
NORITATE 1% CREAM	4	Non-Preferred Brand	40%	40%	None
NORMOSOL -R INJ /D5W	4	Non-Preferred Brand	40%	40%	None
NORMOSOL-M AND DEXTROSE 5%	4	Non-Preferred Brand	40%	40%	None
NORMOSOL-R PH 7.4 IV SOLUTION	4	Non-Preferred Brand	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOROXIN 400mg/1 20 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	40%	40%	None
NORPACE 100MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NORPACE 150MG CAPSULE	4	Non-Preferred Brand	40%	40%	None
NORPACE CR 100MG CAPSULE SA	4	Non-Preferred Brand	40%	40%	None
NORPACE CR 150MG CAPSULE SA	4	Non-Preferred Brand	40%	40%	None
NORPRAMIN 100MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORPRAMIN 10MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORPRAMIN 150MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORPRAMIN 25MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORPRAMIN 50MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORPRAMIN 75MG TABLET	4	Non-Preferred Brand	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK	2	Non-Preferred Generic	$10.00	$27.00	None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Non-Preferred Generic	$10.00	$27.00	None
NORTREL 1-0.035MG TABLET 28DAY	2	Non-Preferred Generic	$10.00	$27.00	None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER	2	Non-Preferred Generic	$10.00	$27.00	None
NORTRIPTYLINE 10 MG/5 ML SOL	2	Non-Preferred Generic	$10.00	$27.00	None
NORTRIPTYLINE HCL 25MG CAP	2	Non-Preferred Generic	$10.00	$27.00	None
NORTRIPTYLINE HCL 75MG CAPSULE	2	Non-Preferred Generic	$10.00	$27.00	None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE	2	Non-Preferred Generic	$10.00	$27.00	None
NORVASC 10MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORVASC 2.5MG TABLET	4	Non-Preferred Brand	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORVASC 5MG TABLET	4	Non-Preferred Brand	40%	40%	None
NORVIR 100 MG TABLET	3	Preferred Brand	25%	25%	None
NORVIR 100mg/1 30 CAPSULE BOTTLE	3	Preferred Brand	25%	25%	None
NORVIR 80MG/ML ORAL SOLUTION	3	Preferred Brand	25%	25%	None
novarel 10,000 units vial	3	Preferred Brand	25%	25%	None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	25%	25%	None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	25%	25%	None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	25%	25%	None
NOVOLOG 100U/ML VIAL	3	Preferred Brand	25%	25%	None
NOVOLOG FLEXPEN SYRINGE	3	Preferred Brand	25%	25%	None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML	3	Preferred Brand	25%	25%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOVOLOG MIX 70/30 VIAL	3	Preferred Brand	25%	25%	None
NOXAFIL 200MG/5ML SUSPENSION ORAL	4	Non-Preferred Brand	40%	40%	None
NOXAFIL DR 100 MG TABLET	4	Non-Preferred Brand	40%	40%	None
NUCYNTA 100mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 FILM COATED TABLETS in BLISTER PACK	3	Preferred Brand	25%	25%	Q:181 /30Days
NUCYNTA 50mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 FILM COATED TABLETS in BLISTER PACK	3	Preferred Brand	25%	25%	Q:181 /30Days
NUCYNTA 75mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 FILM COATED TABLETS in BLISTER PACK	3	Preferred Brand	25%	25%	Q:181 /30Days
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED	3	Preferred Brand	25%	25%	Q:60 /30Days
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED	3	Preferred Brand	25%	25%	Q:60 /30Days
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED	3	Preferred Brand	25%	25%	Q:60 /30Days
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED	3	Preferred Brand	25%	25%	Q:60 /30Days
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED	3	Preferred Brand	25%	25%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NUEDEXTA 20; 10mg/1; mg/1	3	Preferred Brand	25%	25%	None
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in	4	Non-Preferred Brand	40%	40%	P
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT	4	Non-Preferred Brand	40%	40%	None
NUTROPIN 10 MG VIAL	4	Non-Preferred Brand	40%	40%	None
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN	4	Non-Preferred Brand	40%	40%	None
NUTROPIN AQ NUSPIN 10MG/2ML SOLUTION	4	Non-Preferred Brand	40%	40%	None
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML	4	Non-Preferred Brand	40%	40%	None
NUVARING 0.12-0.015 RING VAGINAL	3	Preferred Brand	25%	25%	None
NUVIGIL 150 MG TABLET	3	Preferred Brand	25%	25%	P
NUVIGIL 250 MG TABLET	3	Preferred Brand	25%	25%	P
NUVIGIL 50 MG TABLET	3	Preferred Brand	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NYAMYC 100000 U/G POWDER	2	Non-Preferred Generic	$10.00	$27.00	None
Nystatin 100000[USP'U]/g	2	Non-Preferred Generic	$10.00	$27.00	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	1	Preferred Generic	$3.00	$7.50	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	1	Preferred Generic	$3.00	$7.50	None
Nystatin 100000[USP'U]/mL	2	Non-Preferred Generic	$10.00	$27.00	None
NYSTATIN TABLET 500000U (100 CT)	2	Non-Preferred Generic	$10.00	$27.00	None
NYSTATIN/TRIAMCINOLONE CRM	1	Preferred Generic	$3.00	$7.50	None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG	1	Preferred Generic	$3.00	$7.50	None
NYSTOP 100000U/GM POWDER	2	Non-Preferred Generic	$10.00	$27.00	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Stride (HMO) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2014 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.