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2016 Medicare Part D Plan Formulary Information
Humana Gold Plus H1468-007 (HMO) (H1468-007-0) Benefit Details
The Humana Gold Plus H1468-007 (HMO) (H1468-007-0) Formulary Drugs Starting with the Letter N in McLean County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $25.00 Deductible: $0
Drugs Starting with Letter N Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter N Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NABUMETONE 500MG TABLET	2	Generic	$15.00	$0.00	None
NABUMETONE 750MG TABLET	2	Generic	$15.00	$0.00	None
NADOLOL 20MG TABLET	3	Preferred Brand	$47.00	$131.00	None
NADOLOL 40MG TABLETS	3	Preferred Brand	$47.00	$131.00	None
Nadolol 80mg/1 90 TABLET BOTTLE	3	Preferred Brand	$47.00	$131.00	None
NADOLOL-BENDROFLU 40-5 MG TAB	3	Preferred Brand	$47.00	$131.00	None
NADOLOL-BENDROFLU 80-5 MG TAB	3	Preferred Brand	$47.00	$131.00	None
Nafcillin 1 gm vial	4	Non-Preferred Brand	$100.00	$290.00	None
Nafcillin 10g/100mL	5	Specialty Tier	33%	N/A	None
NAFCILLIN 1GM/50ML INJ	4	Non-Preferred Brand	$100.00	$290.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAFTIFINE HCL 1% CREAM [Naftin]	3	Preferred Brand	$47.00	$131.00	None
Naftifine HCl 2% Cream [Naftin]	3	Preferred Brand	$47.00	$131.00	None
NAFTIN 2% CREAM	3	Preferred Brand	$47.00	$131.00	None
NAFTIN 2% GEL	3	Preferred Brand	$47.00	$131.00	None
NAFTIN HCL GEL 1% 60GM TUBE	3	Preferred Brand	$47.00	$131.00	None
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	$100.00	$290.00	Q:240 /30Days
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Brand	$100.00	$290.00	Q:120 /30Days
NALOXONE 0.4 MG/ML VIAL	2	Generic	$15.00	$0.00	None
naloxone 1 mg/ml syringe	2	Generic	$15.00	$0.00	None
NALTREXONE HCL 50MG TABLET 100 BLPK	2	Generic	$15.00	$0.00	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	$47.00	$131.00	P Q:360 /30Days
NAMENDA XR 14 MG CAPSULE	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
NAMENDA XR 21 MG CAPSULE	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
NAMENDA XR 28 MG CAPSULE	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
NAMENDA XR 7 MG CAPSULE	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
NAMENDA XR TITRATION PACK	3	Preferred Brand	$47.00	$131.00	P Q:28 /28Days
NAMZARIC 14 MG-10 MG CAPSULE	3	Preferred Brand	$47.00	$131.00	S Q:30 /30Days
NAMZARIC 28 MG-10 MG CAPSULE	3	Preferred Brand	$47.00	$131.00	S Q:30 /30Days
Naproxen 125 mg/5 ml suspen	3	Preferred Brand	$47.00	$131.00	None
NAPROXEN 250 MG ORAL TABLET	2	Generic	$15.00	$0.00	None
Naproxen 500mg/1 500 TABLET BOTTLE	2	Generic	$15.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROXEN DR 375 MG TABLET	2	Generic	$15.00	$0.00	None
NAPROXEN DR 500 MG TABLET	2	Generic	$15.00	$0.00	None
NAPROXEN SODIUM 275 MG ORAL TABLET	1	Preferred Generic	$6.00	$0.00	None
NAPROXEN SODIUM 550 MG	1	Preferred Generic	$6.00	$0.00	None
NAPROXEN TABLET 375MG (500 CT)	2	Generic	$15.00	$0.00	None
NARATRIPTAN 1MG TABLETS	3	Preferred Brand	$47.00	$131.00	Q:9 /30Days
NARATRIPTAN 2.5MG TABLETS	3	Preferred Brand	$47.00	$131.00	Q:9 /30Days
NARCAN 4 MG NASAL SPRAY	4	Non-Preferred Brand	$100.00	$290.00	None
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP	3	Preferred Brand	$47.00	$131.00	None
NATACYN EYE DROPS	4	Non-Preferred Brand	$100.00	$290.00	None
Natazia 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	$100.00	$290.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nateglinide 120mg/1 90 TABLET BOTTLE	3	Preferred Brand	$47.00	$131.00	None
Nateglinide 60mg/1 90 TABLET BOTTLE	3	Preferred Brand	$47.00	$131.00	None
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	4	Non-Preferred Brand	$100.00	$290.00	P
NECON 0.5/35-28 TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NECON 1-50-28 TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NECON 1/35-28 TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NECON 10/11-28 TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NECON 7-7-7-28 TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NEFAZODONE HCL 150MG TABLET (60 CT)	4	Non-Preferred Brand	$100.00	$290.00	None
NEFAZODONE HCL 250MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NEFAZODONE HCL 50MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT	4	Non-Preferred Brand	$100.00	$290.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT	4	Non-Preferred Brand	$100.00	$290.00	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	2	Generic	$15.00	$0.00	None
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE	3	Preferred Brand	$47.00	$131.00	None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1	2	Generic	$15.00	$0.00	None
NEOMYCIN SULFATE 500MG TABLET	3	Preferred Brand	$47.00	$131.00	None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT	3	Preferred Brand	$47.00	$131.00	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	4	Non-Preferred Brand	$100.00	$290.00	None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML	2	Generic	$15.00	$0.00	None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M	2	Generic	$15.00	$0.00	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	2	Generic	$15.00	$0.00	None
NEOSPORIN EYE DROPS	2	Generic	$15.00	$0.00	None
NEPHRAMINE SOLUTION FOR INJECTION	4	Non-Preferred Brand	$100.00	$290.00	P
NESINA 12.5 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NESINA 25 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NESINA 6.25 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEULASTA 6MG/0.6ML SYRINGE	5	Specialty Tier	33%	N/A	P Q:1 /28Days
NEUPOGEN 300 MCG/ML VIAL	5	Specialty Tier	33%	N/A	P Q:14 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEUPOGEN 300MCG/ML VIAL	5	Specialty Tier	33%	N/A	P Q:22 /30Days
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE	5	Specialty Tier	33%	N/A	P Q:7 /30Days
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR	5	Specialty Tier	33%	N/A	P Q:11 /30Days
NEUPRO 1 MG/24 HR PATCH	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEUPRO 2 MG/24 HR PATCH	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEUPRO 3 MG/24 HR PATCH	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEUPRO 4 MG/24 HR PATCH	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEUPRO 6 MG/24 HR PATCH	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEUPRO 8 MG/24 HR PATCH	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
nevirapine 200 mg tablet	2	Generic	$15.00	$0.00	Q:60 /30Days
NEVIRAPINE 50 MG/5 ML SUSP	4	Non-Preferred Brand	$100.00	$290.00	Q:1200 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEVIRAPINE ER 100 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	Q:120 /30Days
NEVIRAPINE ER 400 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	Q:30 /30Days
NEXAVAR TABLETS 200MG 120 BOT	5	Specialty Tier	33%	N/A	P Q:120 /30Days
Nexterone 150mg/100mL 100 mL in 1 BAG	4	Non-Preferred Brand	$100.00	$290.00	None
Nexterone 360mg/200mL 200 mL in 1 BAG	4	Non-Preferred Brand	$100.00	$290.00	None
NIACIN ER 1,000 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NIACIN ER 500 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NIACIN ER 750 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	None
NIACOR 500MG TABLET	2	Generic	$15.00	$0.00	None
Nicardipine 25 mg/10 ml vial	2	Generic	$15.00	$0.00	None
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES	3	Preferred Brand	$47.00	$131.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT	3	Preferred Brand	$47.00	$131.00	None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL	4	Non-Preferred Brand	$100.00	$290.00	None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR	3	Preferred Brand	$47.00	$131.00	Q:60 /30Days
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR	3	Preferred Brand	$47.00	$131.00	Q:60 /30Days
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE	3	Preferred Brand	$47.00	$131.00	Q:60 /30Days
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE	3	Preferred Brand	$47.00	$131.00	Q:60 /30Days
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE	3	Preferred Brand	$47.00	$131.00	Q:60 /30Days
Nikki 3 mg-0.02 mg tablet	4	Non-Preferred Brand	$100.00	$290.00	None
NILANDRON 150 MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK	4	Non-Preferred Brand	$100.00	$290.00	None
NINLARO 2.3 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:3 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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	P
Nitrofurantoin 25mg/5mL	4	Non-Preferred Brand	$100.00	$290.00	None
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$290.00	None
Nitrofurantoin mcr 100 mg cap	4	Non-Preferred Brand	$100.00	$290.00	None
NITROFURANTOIN MONO-MCR 100 MG	4	Non-Preferred Brand	$100.00	$290.00	None
NITROFURANTOIN MONO-MCR 25; 75mg 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$290.00	None
NITROGLYCERIN .2MG/HR PATCH	2	Generic	$15.00	$0.00	Q:30 /30Days
NITROGLYCERIN .4MG/HR PATCH	2	Generic	$15.00	$0.00	Q:60 /30Days
NITROGLYCERIN .6MG/HR PATCH	2	Generic	$15.00	$0.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE	2	Generic	$15.00	$0.00	None
NITROGLYCERIN LINGUAL 0.4 MG	4	Non-Preferred Brand	$100.00	$290.00	None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX	2	Generic	$15.00	$0.00	Q:30 /30Days
Nitrolingual Pumpspray 400ug/1 200 SPRAY, METERED in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$290.00	None
NITROSTAT 0.3MG TABLET SL	3	Preferred Brand	$47.00	$131.00	None
NITROSTAT 0.4MG TABLET SL	3	Preferred Brand	$47.00	$131.00	None
NITROSTAT 0.6MG TABLET SL	3	Preferred Brand	$47.00	$131.00	None
Nizatidine 150mg/1 60 CAPSULE in 1 BOTTLE	3	Preferred Brand	$47.00	$131.00	None
NIZATIDINE 300 MG CAPSULE (100 CAPS)	3	Preferred Brand	$47.00	$131.00	None
NIZATIDINE ORAL SOLUTION 15MG/ML	3	Preferred Brand	$47.00	$131.00	None
NOR-QD TABLET 0.35MG	4	Non-Preferred Brand	$100.00	$290.00	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	$100.00	$290.00	None
Norethin-Estrad-Ferr 1-0.02 mg	4	Non-Preferred Brand	$100.00	$290.00	None
Norethindrone 0.35 mg tablet	4	Non-Preferred Brand	$100.00	$290.00	None
NORETHINDRONE 5MG TABLET	3	Preferred Brand	$47.00	$131.00	None
NORG-EE 0.18-0.215-0.25/0.025	4	Non-Preferred Brand	$100.00	$290.00	None
NORINYL 1+35-28 TABLET 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	$100.00	$290.00	None
Norinyl 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	4	Non-Preferred Brand	$100.00	$290.00	None
Norlyroc 0.35 mg tablet	4	Non-Preferred Brand	$100.00	$290.00	None
NORMOSOL -R INJ /D5W	4	Non-Preferred Brand	$100.00	$290.00	None
NORMOSOL-M AND DEXTROSE 5%	4	Non-Preferred Brand	$100.00	$290.00	None
NORMOSOL-R PH 7.4 IV SOLUTION	4	Non-Preferred Brand	$100.00	$290.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORTHERA 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:90 /30Days
NORTHERA 200 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:90 /30Days
NORTHERA 300 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:180 /30Days
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK	4	Non-Preferred Brand	$100.00	$290.00	None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	$100.00	$290.00	None
NORTREL 1-0.035MG TABLET 28DAY	4	Non-Preferred Brand	$100.00	$290.00	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	$100.00	$290.00	None
NORTRIPTYLINE 10 MG/5 ML SOL	3	Preferred Brand	$47.00	$131.00	None
NORTRIPTYLINE HCL 25MG CAP	2	Generic	$15.00	$0.00	None
NORTRIPTYLINE HCL 75MG CAPSULE	2	Generic	$15.00	$0.00	None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE	2	Generic	$15.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE	2	Generic	$15.00	$0.00	None
NORVIR 100 MG TABLET	4	Non-Preferred Brand	$100.00	$290.00	Q:360 /30Days
NORVIR 100mg/1 30 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$290.00	Q:360 /30Days
NORVIR 80MG/ML ORAL SOLUTION	4	Non-Preferred Brand	$100.00	$290.00	Q:480 /30Days
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$47.00	$131.00	None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$47.00	$131.00	None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$47.00	$131.00	None
NOVOLOG 100 UNIT/ML CARTRIDGE	3	Preferred Brand	$47.00	$131.00	None
NOVOLOG 100U/ML VIAL	3	Preferred Brand	$47.00	$131.00	None
NOVOLOG FLEXPEN SYRINGE	3	Preferred Brand	$47.00	$131.00	None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML	3	Preferred Brand	$47.00	$131.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOVOLOG MIX 70/30 VIAL	3	Preferred Brand	$47.00	$131.00	None
NOXAFIL 200MG/5ML SUSPENSION ORAL	5	Specialty Tier	33%	N/A	P Q:840 /28Days
NOXAFIL DR 100 MG TABLET	5	Specialty Tier	33%	N/A	P Q:93 /30Days
NUEDEXTA 20; 10mg/1; mg/1	3	Preferred Brand	$47.00	$131.00	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 Q:200 /30Days
NUPLAZID 17 MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
NUTRILIPID 20 % EMULSION	4	Non-Preferred Brand	$100.00	$290.00	P
NUTRILIPID 20% IV FAT EMULSION	4	Non-Preferred Brand	$100.00	$290.00	P
NUVARING 0.12-0.015 RING VAGINAL	4	Non-Preferred Brand	$100.00	$290.00	Q:1 /28Days
NUVIGIL 150 MG TABLET	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
NUVIGIL 200 MG TABLET	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NUVIGIL 250 MG TABLET	3	Preferred Brand	$47.00	$131.00	P Q:30 /30Days
NUVIGIL 50 MG TABLET	3	Preferred Brand	$47.00	$131.00	P Q:60 /30Days
NYAMYC 100000 U/G POWDER	2	Generic	$15.00	$0.00	None
Nystatin 100000[USP'U]/g	2	Generic	$15.00	$0.00	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Generic	$15.00	$0.00	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Generic	$15.00	$0.00	None
Nystatin 100000[USP'U]/mL	2	Generic	$15.00	$0.00	None
NYSTATIN TABLET 500000U (100 CT)	2	Generic	$15.00	$0.00	None
NYSTATIN/TRIAMCINOLONE CRM	4	Non-Preferred Brand	$100.00	$290.00	None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG	4	Non-Preferred Brand	$100.00	$290.00	None
NYSTOP 100000U/GM POWDER	2	Generic	$15.00	$0.00	None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Humana Gold Plus H1468-007 (HMO) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $360 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2016 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.