2015 Medicare Part D Plan Formulary Information |
Gateway Health Medicare Assured Choice (HMO) (H9190-017-0)
Benefit Details
|
The Gateway Health Medicare Assured Choice (HMO) (H9190-017-0) Formulary Drugs Starting with the Letter N in OWSLEY County, KY: CMS MA Region 13 which includes: KY Plan Monthly Premium: $57.90 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 |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NABUMETONE 750MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NADOLOL 20MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NADOLOL 40MG TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NAFCILLIN 1GM/50ML INJ |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
naloxone 1 mg/ml syringe |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NAMENDA 10MG TABLET |
3 |
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 10MG/5ML SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:360 /30Days |
NAMENDA 5-10MG TITRATION PK |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA 5MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NAMENDA XR 14 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
NAMENDA XR 21 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
NAMENDA XR 28 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
NAMENDA XR TITRATION PACK |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
NAPROXEN 125 MG/5 ML SUSPEN |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NAPROXEN 375MG TABLET EC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 500MG TABLET EC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Naproxen Sodium 550mg/1 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NATACYN EYE DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Nateglinide 60mg/1 90 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NECON 0.5/35-28 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NECON 1/35-28 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NECON 10/11-28 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NECON 7-7-7-28 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEFAZODONE HCL 250MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEFAZODONE HCL 50MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | 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 |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEOSPORIN EYE DROPS |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
NEUPOGEN 300 MCG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
33% | N/A | P |
nevirapine 200 mg tablet |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEVIRAPINE 50 MG/5 ML SUSP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
nevirapine er 400 mg tablet |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
NIACIN ER 1,000 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NIACIN ER 500 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NIACIN ER 750 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NIACOR 500MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nifedipine 10mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
NIFEDIPINE 20MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NILANDRON 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NIPENT FOR INJECTION 10MG VIALS |
5 |
Specialty Tier |
33% | N/A | P |
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NITRO-DUR 0.3 MG/HR PATCH |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NITRO-DUR 0.8 MG/HR PATCH |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin 25mg/5mL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
Nitrofurantoin mcr 100 mg cap |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
NITROGLYCERIN .2MG/HR PATCH |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN LINGUAL 0.4 MG |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NITROSTAT 0.4MG TABLET SL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NORA-BE 0.35MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | P |
NORDITROPIN NORDIFLEX 30MG/3ML INJECTION |
5 |
Specialty Tier |
33% | N/A | P |
Norethindrone 0.35 mg tablet |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Norlyroc 0.35 mg tablet |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTREL 1-0.035MG TABLET 28DAY |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | 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 |
$20.00 | $40.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NORVIR 100 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
3 |
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[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG 100 UNIT/ML CARTRIDGE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG 100U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG FLEXPEN SYRINGE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NOVOLOG MIX 70/30 VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
33% | N/A | P |
NUEDEXTA 20; 10mg/1; mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P Q:60 /30Days |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier |
33% | N/A | None |
NUTRILIPID 20% IV FAT EMULSION |
3 |
Preferred Brand |
$45.00 | $90.00 | 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 |
$45.00 | $90.00 | Q:1 /28Days |
NYAMYC 100000 U/G POWDER |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/g |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/mL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
NYSTOP 100000U/GM POWDER |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |