2015 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Saver (PDP) (S5810-065-0)
Benefit Details
 |
The Aetna Medicare Rx Saver (PDP) (S5810-065-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $31.40 Deductible: $320 Qualifies for LIS: Yes |
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 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NABUMETONE 750MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NADOLOL 20MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NADOLOL 40MG TABLETS  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Nadolol 80mg/1 90 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NADOLOL-BENDROFLU 40-5 MG TAB  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NADOLOL-BENDROFLU 80-5 MG TAB  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NAFCILLIN 1GM/50ML INJ  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NAGLAZYME 5MG/5ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
naloxone 1 mg/ml syringe  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NAMENDA XR 14 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:30 /30Days |
NAMENDA XR 21 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:30 /30Days |
NAMENDA XR 28 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:30 /30Days |
NAMENDA XR TITRATION PACK  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:30 /30Days |
NAPROXEN 125 MG/5 ML SUSPEN  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NAPROXEN 250 MG ORAL TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NAPROXEN 375MG TABLET EC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 500MG TABLET EC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Naproxen Sodium 550mg/1  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NAPROXEN TABLET 375MG (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NARATRIPTAN 1MG TABLETS  |
4 |
Non-Preferred Brand |
36% | 36% | Q:9 /30Days |
NARATRIPTAN 2.5MG TABLETS  |
4 |
Non-Preferred Brand |
36% | 36% | Q:9 /30Days |
Nateglinide 120mg/1 90 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nateglinide 60mg/1 90 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NEBUPENT 300MG INHAL POWDER  |
4 |
Non-Preferred Brand |
36% | 36% | P |
NECON 0.5/35-28 TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NECON 1-50-28 TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NECON 1/35-28 TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NECON 10/11-28 TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NECON 7-7-7-28 TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEFAZODONE HCL 150MG TABLET (60 CT)  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEFAZODONE HCL 250MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEFAZODONE HCL 50MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 ![Compare how all Medicare Part D PDP plans in ID cover Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 .](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN SULFATE 500MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | P |
NEUPOGEN 300 MCG/ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300MCG/ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE  |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 1 MG/24 HR PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
NEUPRO 4 MG/24 HR PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
NEUPRO 6 MG/24 HR PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
NEVANAC 0.1% DROPTAINER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
nevirapine 200 mg tablet  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEVIRAPINE 50 MG/5 ML SUSP  |
4 |
Non-Preferred Brand |
36% | 36% | None |
nevirapine er 400 mg tablet  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NEXAVAR TABLETS 200MG 120 BOT  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIACIN ER 1,000 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NIACIN ER 500 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NIACIN ER 750 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL  |
4 |
Non-Preferred Brand |
36% | 36% | Q:40 /30Days |
Nikki 3 mg-0.02 mg tablet  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NILANDRON 150 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NIPENT FOR INJECTION 10MG VIALS  |
5 |
Specialty Tier |
25% | N/A | None |
Nitrofurantoin 25mg/5mL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin mcr 100 mg cap  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NITROGLYCERIN .2MG/HR PATCH  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NITROGLYCERIN .4MG/HR PATCH  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NITROGLYCERIN .6MG/HR PATCH  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NITROGLYCERIN LINGUAL 0.4 MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NITROSTAT 0.3MG TABLET SL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NITROSTAT 0.4MG TABLET SL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NITROSTAT 0.6MG TABLET SL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORA-BE 0.35MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC  |
5 |
Specialty Tier |
25% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC  |
5 |
Specialty Tier |
25% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC  |
5 |
Specialty Tier |
25% | N/A | P |
NORDITROPIN NORDIFLEX 30MG/3ML INJECTION  |
5 |
Specialty Tier |
25% | N/A | P |
Norethin-Estrad-Ferr 0.8-0.025 MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Norethin-Estrad-Ferr 1-0.02 mg  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Norethindrone 0.35 mg tablet  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NORETHINDRONE 5MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Norinyl 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Norlyroc 0.35 mg tablet  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NORTREL 1-0.035MG TABLET 28DAY  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NORTRIPTYLINE 10 MG/5 ML SOL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NORTRIPTYLINE HCL 25MG CAP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NORVIR 100 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 100mg/1 30 CAPSULE BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
NORVIR 80MG/ML ORAL SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in ID cover Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in ID cover Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in ID cover Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
NOVOLOG 100 UNIT/ML CARTRIDGE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
NOVOLOG 100U/ML VIAL  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
NOVOLOG FLEXPEN SYRINGE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
NOVOLOG MIX 70/30 VIAL  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NOXAFIL DR 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
NUEDEXTA 20; 10mg/1; mg/1  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in  |
5 |
Specialty Tier |
25% | N/A | P |
NUTRILIPID 20% IV FAT EMULSION  |
4 |
Non-Preferred Brand |
36% | 36% | P |
NYAMYC 100000 U/G POWDER  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nystatin 100000[USP'U]/g ![Compare how all Medicare Part D PDP plans in ID cover Nystatin 100000[USP'U]/g.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in ID cover Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in ID cover Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Nystatin 100000[USP'U]/mL ![Compare how all Medicare Part D PDP plans in ID cover Nystatin 100000[USP'U]/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NYSTATIN TABLET 500000U (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
NYSTOP 100000U/GM POWDER  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |