2016 Medicare Part D Plan Formulary Information |
Amerivantage Classic (HMO) (H7200-007-0)
Benefit Details
|
The Amerivantage Classic (HMO) (H7200-007-0) Formulary Drugs Starting with the Letter N in Benton County, TN: CMS MA Region 10 which includes: TN Plan Monthly Premium: $0.00 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 |
2 |
Generic |
$10.00 | $30.00 | None |
NABUMETONE 750MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
NADOLOL 20MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NADOLOL 40MG TABLETS |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NADOLOL-BENDROFLU 40-5 MG TAB |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NADOLOL-BENDROFLU 80-5 MG TAB |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Nafcillin 1 gm vial |
5 |
Specialty Tier |
33% | N/A | None |
Nafcillin 10g/100mL |
5 |
Specialty Tier |
33% | N/A | None |
NAFCILLIN 1GM/50ML INJ |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:180 /30Days |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:90 /30Days |
NALOXONE 0.4 MG/ML VIAL |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
naloxone 1 mg/ml syringe |
2 |
Generic |
$10.00 | $30.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
2 |
Generic |
$10.00 | $30.00 | None |
NAMENDA 10MG/5ML SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:300 /30Days |
NAMENDA XR 14 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NAMENDA XR 21 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NAMENDA XR 28 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA XR TITRATION PACK |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:56 /365Days |
NAMZARIC 14 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NAMZARIC 28 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Naproxen 125 mg/5 ml suspen |
2 |
Generic |
$10.00 | $30.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN DR 375 MG TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN DR 500 MG TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN SODIUM 550 MG |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARATRIPTAN 1MG TABLETS |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:9 /30Days |
NARATRIPTAN 2.5MG TABLETS |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:9 /30Days |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:17 /30Days |
Nateglinide 120mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:90 /30Days |
Nateglinide 60mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:180 /30Days |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
NATPARA 25 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
NECON 0.5/35-28 TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | 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 |
$83.00 | $249.00 | None |
NECON 1/35-28 TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NECON 10/11-28 TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NECON 7-7-7-28 TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:120 /30Days |
NEFAZODONE HCL 250MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:72 /30Days |
NEFAZODONE HCL 50MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:360 /30Days |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /30Days |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Generic |
$10.00 | $30.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | 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 |
2 |
Generic |
$10.00 | $30.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
2 |
Generic |
$10.00 | $30.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Generic |
$10.00 | $30.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | 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 |
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 |
5 |
Specialty Tier |
33% | N/A | P |
NEUPRO 1 MG/24 HR PATCH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NEUPRO 4 MG/24 HR PATCH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NEUPRO 6 MG/24 HR PATCH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
NEVANAC 0.1% DROPTAINER |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
nevirapine 200 mg tablet |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
NEVIRAPINE 50 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:1200 /30Days |
NEVIRAPINE ER 100 MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEVIRAPINE ER 400 MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:30 /30Days |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
NIACIN ER 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:60 /30Days |
NIACIN ER 500 MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:30 /30Days |
NIACIN ER 750 MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:60 /30Days |
NIACOR 500MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Nicardipine 25 mg/10 ml vial |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES |
2 |
Generic |
$10.00 | $30.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
2 |
Generic |
$10.00 | $30.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:120 /30Days |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Generic |
$10.00 | $30.00 | 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 |
2 |
Generic |
$10.00 | $30.00 | None |
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE |
2 |
Generic |
$10.00 | $30.00 | None |
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE |
2 |
Generic |
$10.00 | $30.00 | None |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NILANDRON 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NINLARO 2.3 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:3 /28Days |
NINLARO 3 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:3 /28Days |
NINLARO 4 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:3 /28Days |
NIPENT FOR INJECTION 10MG VIALS |
5 |
Specialty Tier |
33% | N/A | None |
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | P |
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 |
$83.00 | $249.00 | P |
NITROFURANTOIN MONO-MCR 100 MG |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | P |
NITROFURANTOIN MONO-MCR 25; 75mg 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | P |
NITROGLYCERIN .2MG/HR PATCH |
2 |
Generic |
$10.00 | $30.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
2 |
Generic |
$10.00 | $30.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
2 |
Generic |
$10.00 | $30.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | P |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2 |
Generic |
$10.00 | $30.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NITROSTAT 0.4MG TABLET SL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nizatidine 150mg/1 60 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NOR-QD TABLET 0.35MG |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORA-BE 0.35MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | 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 FLEXPRO 30 MG/3 ML |
5 |
Specialty Tier |
33% | N/A | P |
Norethindrone 0.35 mg tablet |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORETHINDRONE 5MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORMOSOL -R INJ /D5W |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORPACE 100MG CAPSULE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | P |
NORPACE 150MG CAPSULE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | P |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | 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 |
$83.00 | $249.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
2 |
Generic |
$10.00 | $30.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$10.00 | $30.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE |
2 |
Generic |
$10.00 | $30.00 | None |
NORVASC 10MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:30 /30Days |
NORVASC 2.5MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:30 /30Days |
NORVASC 5MG TABLET |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:45 /30Days |
NORVIR 100 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:360 /30Days |
NORVIR 80MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | Q:480 /30Days |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
33% | N/A | P Q:630 /30Days |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Preferred Brand |
$42.00 | $126.00 | 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 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUPLAZID 17 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
NYAMYC 100000 U/G POWDER |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Nystatin 100000[USP'U]/g |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Generic |
$10.00 | $30.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Nystatin 100000[USP'U]/mL |
2 |
Generic |
$10.00 | $30.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
2 |
Generic |
$10.00 | $30.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
4 |
Non-Preferred Brand |
$83.00 | $249.00 | None |
NYSTOP 100000U/GM POWDER |
3 |
Preferred Brand |
$42.00 | $126.00 | None |