2016 Medicare Part D Plan Formulary Information |
Optimum Emerald Full (HMO SNP) (H5594-017-0)
Benefit Details
|
The Optimum Emerald Full (HMO SNP) (H5594-017-0) Formulary Drugs Starting with the Letter N in Polk County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $28.00 Deductible: $360 |
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 |
$0.00 | $0.00 | None |
NABUMETONE 750MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NADOLOL 20MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NADOLOL 40MG TABLETS |
1* |
Generic |
$0.00 | $0.00 | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Nafcillin 1 gm vial |
1* |
Generic |
$0.00 | $0.00 | None |
Nafcillin 10g/100mL |
1* |
Generic |
$0.00 | $0.00 | None |
NAFCILLIN 1GM/50ML INJ |
1* |
Generic |
$0.00 | $0.00 | None |
NAGLAZYME 5MG/5ML VIAL |
4 |
Specialty Tier |
25% | 25% | P |
NALOXONE 0.4 MG/ML VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
naloxone 1 mg/ml syringe |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1* |
Generic |
$0.00 | $0.00 | None |
NAMENDA 10MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
NAMENDA 10MG/5ML SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:300 /30Days |
NAMENDA 5-10MG TITRATION PK |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NAMENDA 5MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:60 /30Days |
NAMENDA XR TITRATION PACK |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Naproxen 125 mg/5 ml suspen |
1* |
Generic |
$0.00 | $0.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
NAPROXEN DR 375 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN DR 500 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NAPROXEN SODIUM 550 MG |
1* |
Generic |
$0.00 | $0.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
NARDIL 15MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:34 /30Days |
NATACYN EYE DROPS |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NATPARA 100 MCG DOSE CARTRIDGE |
4 |
Specialty Tier |
25% | 25% | P |
NATPARA 25 MCG DOSE CARTRIDGE |
4 |
Specialty Tier |
25% | 25% | P |
NATPARA 50 MCG DOSE CARTRIDGE |
4 |
Specialty Tier |
25% | 25% | P |
NATPARA 75 MCG DOSE CARTRIDGE |
4 |
Specialty Tier |
25% | 25% | P |
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 |
$95.00 | $285.00 | P |
NECON 10/11-28 TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NECON 7-7-7-28 TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NEFAZODONE HCL 250MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NEFAZODONE HCL 50MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1* |
Generic |
$0.00 | $0.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE |
1* |
Generic |
$0.00 | $0.00 | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN SULFATE 500MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1* |
Generic |
$0.00 | $0.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
NEULASTA 6MG/0.6ML SYRINGE |
4 |
Specialty Tier |
25% | 25% | P |
NEUPOGEN 300 MCG/ML VIAL |
4 |
Specialty Tier |
25% | 25% | P |
NEUPOGEN 300MCG/ML VIAL |
4 |
Specialty Tier |
25% | 25% | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
4 |
Specialty Tier |
25% | 25% | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
4 |
Specialty Tier |
25% | 25% | P |
NEUPRO 1 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 4 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
NEUPRO 6 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
NEURONTIN 250MG/5ML TUBEX |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
4 |
Specialty Tier |
25% | 25% | P |
NEXIUM IV 40MG VIAL |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
NIASPAN 1000MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NIASPAN ER 500MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NIASPAN ER 750MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES |
1* |
Generic |
$0.00 | $0.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
NILANDRON 150 MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NINLARO 2.3 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | Q:3 /28Days |
NINLARO 3 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | Q:3 /28Days |
NINLARO 4 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | Q:3 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
Nitrofurantoin mcr 100 mg cap |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
NITROFURANTOIN MONO-MCR 100 MG |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
NITROFURANTOIN MONO-MCR 25; 75mg 100 CAPSULE BOTTLE |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
NITROGLYCERIN .2MG/HR PATCH |
1* |
Generic |
$0.00 | $0.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
1* |
Generic |
$0.00 | $0.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
1* |
Generic |
$0.00 | $0.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
1* |
Generic |
$0.00 | $0.00 | P |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1* |
Generic |
$0.00 | $0.00 | None |
NITROSTAT 0.3MG TABLET SL |
1* |
Generic |
$0.00 | $0.00 | None |
NITROSTAT 0.4MG TABLET SL |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROSTAT 0.6MG TABLET SL |
1* |
Generic |
$0.00 | $0.00 | None |
Nizatidine 150mg/1 60 CAPSULE in 1 BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
1* |
Generic |
$0.00 | $0.00 | None |
NORETHINDRONE 5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
NORMOSOL -R INJ /D5W |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NORMOSOL-M AND DEXTROSE 5% |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NORTHERA 100 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | P |
NORTHERA 200 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | P |
NORTHERA 300 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | P |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
1* |
Generic |
$0.00 | $0.00 | 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 per CARTON / 1 KIT per BLISTER PACK |
1* |
Generic |
$0.00 | $0.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
1* |
Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
1* |
Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1* |
Generic |
$0.00 | $0.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
NORVIR 100 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:40 /30Days |
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 |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:40 /30Days |
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:40 /30Days |
NOVOLOG 100 UNIT/ML CARTRIDGE |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:45 /30Days |
NOVOLOG 100U/ML VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:40 /30Days |
NOVOLOG FLEXPEN SYRINGE |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:45 /30Days |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:45 /30Days |
NOVOLOG MIX 70/30 VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:40 /30Days |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
4 |
Specialty Tier |
25% | 25% | P |
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUPLAZID 17 MG TABLET |
4 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN |
4 |
Specialty Tier |
25% | 25% | P |
NUTROPIN AQ NUSPIN 10 INJECTOR |
4 |
Specialty Tier |
25% | 25% | P |
NUTROPIN AQ NUSPIN 20 INJECTOR |
4 |
Specialty Tier |
25% | 25% | P |
NUVARING 0.12-0.015 RING VAGINAL |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
NYAMYC 100000 U/G POWDER |
1* |
Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g |
1* |
Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1* |
Generic |
$0.00 | $0.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Nystatin 100000[USP'U]/mL |
1* |
Generic |
$0.00 | $0.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN/TRIAMCINOLONE CRM |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
NYSTOP 100000U/GM POWDER |
1* |
Generic |
$0.00 | $0.00 | None |