2015 Medicare Part D Plan Formulary Information |
ADVANTAGE Select (PPO) (PPO) (H5508-005-0)
Benefit Details
|
The ADVANTAGE Select (PPO) (PPO) (H5508-005-0) Formulary Drugs Starting with the Letter N in HANCOCK County, IN: CMS MA Region 13 which includes: IN Plan Monthly Premium: $22.00 Deductible: $0 |
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 |
$10.00 | $20.00 | None |
NABUMETONE 750MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NADOLOL 20MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NADOLOL 40MG TABLETS |
1 |
Generic |
$10.00 | $20.00 | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
NADOLOL-BENDROFLU 40-5 MG TAB |
1 |
Generic |
$10.00 | $20.00 | None |
NADOLOL-BENDROFLU 80-5 MG TAB |
1 |
Generic |
$10.00 | $20.00 | None |
Nafcillin 1 gm vial |
1 |
Generic |
$10.00 | $20.00 | None |
Nafcillin 10g/100mL |
1 |
Generic |
$10.00 | $20.00 | None |
NAFTIFINE HCL 1% CREAM [Naftin] |
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 |
NAFTIN 1% CREAM |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NAFTIN 2% CREAM |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NAFTIN HCL GEL 1% 60GM TUBE |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NAGLAZYME 5MG/5ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
naloxone 1 mg/ml syringe |
1 |
Generic |
$10.00 | $20.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1 |
Generic |
$10.00 | $20.00 | None |
NAMENDA 10MG/5ML SOLUTION |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA XR 14 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA XR 21 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA XR 28 MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA XR 7 MG 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 |
NAMENDA XR TITRATION PACK |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NAPROXEN 125 MG/5 ML SUSPEN |
1 |
Generic |
$10.00 | $20.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NAPROXEN 375MG TABLET EC |
1 |
Generic |
$10.00 | $20.00 | None |
NAPROXEN 500MG TABLET EC |
1 |
Generic |
$10.00 | $20.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
Naproxen Sodium 550mg/1 |
1 |
Generic |
$10.00 | $20.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
5 |
Select Care Drugs |
$2.50 | $5.00 | None |
Nateglinide 60mg/1 90 TABLET BOTTLE |
5 |
Select Care Drugs |
$2.50 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEBUPENT 300MG INHAL POWDER |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
NEFAZODONE HCL 150MG TABLET (60 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
NEFAZODONE HCL 250MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NEFAZODONE HCL 50MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1 |
Generic |
$10.00 | $20.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE |
1 |
Generic |
$10.00 | $20.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
1 |
Generic |
$10.00 | $20.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
1 |
Generic |
$10.00 | $20.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1 |
Generic |
$10.00 | $20.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
1 |
Generic |
$10.00 | $20.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1 |
Generic |
$10.00 | $20.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
2 |
Preferred Brand |
$45.00 | $90.00 | P |
NESINA 12.5 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NESINA 25 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NESINA 6.25 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEUPOGEN 300 MCG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
NEUPOGEN 300MCG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
4 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
4 |
Specialty Tier |
33% | 33% | None |
NEUPRO 1 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEUPRO 2 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEUPRO 3 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEUPRO 4 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEUPRO 6 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEUPRO 8 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEVANAC 0.1% DROPTAINER |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
nevirapine 200 mg tablet |
1 |
Generic |
$10.00 | $20.00 | None |
NEVIRAPINE 50 MG/5 ML SUSP |
1 |
Generic |
$10.00 | $20.00 | None |
nevirapine er 400 mg tablet |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEXAVAR TABLETS 200MG 120 BOT |
4 |
Specialty Tier |
33% | 33% | None |
NEXIUM DR 2.5 MG PACKET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NEXIUM DR 5 MG PACKET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NIACIN ER 1,000 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NIACIN ER 500 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NIACIN ER 750 MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NIACOR 500MG TABLET |
1 |
Generic |
$10.00 | $20.00 | None |
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES |
1 |
Generic |
$10.00 | $20.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1 |
Generic |
$10.00 | $20.00 | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:504 /30Days |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Generic |
$10.00 | $20.00 | None |
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE |
1 |
Generic |
$10.00 | $20.00 | None |
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE |
1 |
Generic |
$10.00 | $20.00 | None |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
1 |
Generic |
$10.00 | $20.00 | None |
NILANDRON 150 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK |
1 |
Generic |
$10.00 | $20.00 | None |
NIPENT FOR INJECTION 10MG VIALS |
5 |
Select Care Drugs |
$2.50 | $5.00 | P |
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
NISOLDIPINE 20MG TB24 |
1 |
Generic |
$10.00 | $20.00 | None |
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
NISOLDIPINE 30MG TB24 |
1 |
Generic |
$10.00 | $20.00 | 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 |
1 |
Generic |
$10.00 | $20.00 | None |
NISOLDIPINE 40MG TB24 |
1 |
Generic |
$10.00 | $20.00 | None |
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $20.00 | None |
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | P |
Nitrofurantoin mcr 100 mg cap |
1 |
Generic |
$10.00 | $20.00 | P |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE |
1 |
Generic |
$10.00 | $20.00 | P |
NITROGLYCERIN .2MG/HR PATCH |
1 |
Generic |
$10.00 | $20.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
1 |
Generic |
$10.00 | $20.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
1 |
Generic |
$10.00 | $20.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
1 |
Generic |
$10.00 | $20.00 | None |
NITROGLYCERIN LINGUAL 0.4 MG |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1 |
Generic |
$10.00 | $20.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NITROSTAT 0.4MG TABLET SL |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Nizatidine 150mg/1 60 CAPSULE in 1 BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
1 |
Generic |
$10.00 | $20.00 | None |
Norethindrone 0.35 mg tablet |
1 |
Generic |
$10.00 | $20.00 | None |
NORETHINDRONE 5MG TABLET |
1 |
Generic |
$10.00 | $20.00 | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTHERA 100 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
NORTHERA 200 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
NORTHERA 300 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
NORTRIPTYLINE 10 MG/5 ML SOL |
1 |
Generic |
$10.00 | $20.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Generic |
$10.00 | $20.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Generic |
$10.00 | $20.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE |
1 |
Generic |
$10.00 | $20.00 | None |
NORVIR 100 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
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 |
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG 100 UNIT/ML CARTRIDGE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG 100U/ML VIAL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG FLEXPEN SYRINGE |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG MIX 70/30 VIAL |
2 |
Preferred Brand |
$45.00 | $90.00 | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NOXAFIL DR 100 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
NUEDEXTA 20; 10mg/1; mg/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 |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
4 |
Specialty Tier |
33% | 33% | P |
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN |
4 |
Specialty Tier |
33% | 33% | P |
NUTROPIN AQ NUSPIN 10MG/2ML SOLUTION |
4 |
Specialty Tier |
33% | 33% | P |
NYAMYC 100000 U/G POWDER |
1 |
Generic |
$10.00 | $20.00 | None |
Nystatin 100000[USP'U]/g |
1 |
Generic |
$10.00 | $20.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Generic |
$10.00 | $20.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Generic |
$10.00 | $20.00 | None |
Nystatin 100000[USP'U]/mL |
1 |
Generic |
$10.00 | $20.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Generic |
$10.00 | $20.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
1 |
Generic |
$10.00 | $20.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
1 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTOP 100000U/GM POWDER |
1 |
Generic |
$10.00 | $20.00 | None |