2017 Medicare Part D Plan Formulary Information |
HealthPartners UnityPoint Health Align (PPO) (H3416-001-5)
Benefit Details
|
The HealthPartners UnityPoint Health Align (PPO) (H3416-001-5) Formulary Drugs Starting with the Letter N in Webster County, IA: CMS MA Region 19 which includes: IA Plan Monthly Premium: $0.00 Deductible: $200 |
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 500 mg tablet |
2* |
Generic |
$20.00 | $40.00 | None |
Nabumetone 750 mg tablet |
2* |
Generic |
$20.00 | $40.00 | None |
NADOLOL 20MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NADOLOL 40MG TABLETS |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Nafcillin 1 gm vial |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
Nafcillin 10g/100mL |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
NALOXONE 0.4 MG/ML VIAL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
naloxone 1 mg/ml syringe |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NALTREXONE HCL 50MG TABLET 100 BLPK |
2* |
Generic |
$20.00 | $40.00 | None |
Naproxen 125 mg/5 ml suspen |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
Naproxen 375 mg tablet |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
NAPROXEN DR 375 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NAPROXEN DR 500 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NAPROXEN SODIUM 550 MG |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NARATRIPTAN 2.5MG TABLETS |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:12 /30Days |
NARATRIPTAN HCL 1 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARCAN 4 MG NASAL SPRAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NATACYN EYE DROPS |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
2* |
Generic |
$20.00 | $40.00 | None |
Nateglinide 60mg/1 90 TABLET BOTTLE |
2* |
Generic |
$20.00 | $40.00 | None |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
29% | N/A | P |
NATPARA 25 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
29% | N/A | P |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
29% | N/A | P |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
29% | N/A | P |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
Necon 0.5-35-28 tablet |
2* |
Generic |
$20.00 | $40.00 | None |
NECON 1-50-28 TABLET |
2* |
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* |
Generic |
$20.00 | $40.00 | None |
NECON 7-7-7-28 TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NEFAZODONE HCL 250MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NEFAZODONE HCL 50MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2* |
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* |
Generic |
$20.00 | $40.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
2* |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2* |
Generic |
$20.00 | $40.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2* |
Generic |
$20.00 | $40.00 | None |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | None |
NEUPOGEN 300 MCG/ML VIAL |
5 |
Specialty Tier |
29% | N/A | None |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
29% | N/A | None |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
29% | N/A | None |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
29% | N/A | None |
NEUPRO 1 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
NEUPRO 2 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
NEUPRO 3 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
NEUPRO 4 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 6 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
NEUPRO 8 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
NEVANAC 0.1% DROPTAINER |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
nevirapine 200 mg tablet |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NEVIRAPINE 50 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
NEVIRAPINE ER 100 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
NEVIRAPINE ER 400 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
29% | N/A | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDIPINE ER 30 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NIFEDIPINE ER 30 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NIFEDIPINE ER 60 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NIFEDIPINE ER 60 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
NIFEDIPINE ER 90 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
Nikki 3 mg-0.02 mg tablet |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Nilutamide 150 mg tablet [Nilandron] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK |
5 |
Specialty Tier |
29% | N/A | None |
NINLARO 2.3 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P |
NINLARO 3 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P |
NINLARO 4 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin 25mg/5mL |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
2* |
Generic |
$20.00 | $40.00 | None |
Nitrofurantoin mcr 100 mg cap |
2* |
Generic |
$20.00 | $40.00 | None |
NITROFURANTOIN MCR 25 MG CAP |
2* |
Generic |
$20.00 | $40.00 | None |
NITROFURANTOIN MONO-MCR 100 MG |
2* |
Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN .2MG/HR PATCH |
2* |
Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
2* |
Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
2* |
Generic |
$20.00 | $40.00 | None |
NITROGLYCERIN 0.3 MG TABLET SL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NITROGLYCERIN 0.4 MG TABLET SL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NITROGLYCERIN 0.6 MG TABLET SL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2* |
Generic |
$20.00 | $40.00 | None |
NORA-BE 0.35MG TABLET |
2* |
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 |
29% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
29% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
29% | N/A | P |
NORDITROPIN FLEXPRO 30 MG/3 ML |
5 |
Specialty Tier |
29% | N/A | P |
noret-estr-fe 0.4-0.035(21)-75 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Norethin-Estrad-Ferr 0.8-0.025 MG |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Norethin-Estrad-Ferr 1-0.02 mg |
2* |
Generic |
$20.00 | $40.00 | None |
NORETHIN-ETH ESTRAD 0.5-2.5 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
norethind-eth estrad 1-0.02 mg |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Norethindrone 0.35 mg tablet |
2* |
Generic |
$20.00 | $40.00 | None |
NORETHINDRONE 5MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NORG-EE 0.18-0.215-0.25/0.025 |
2* |
Generic |
$20.00 | $40.00 | None |
norg-ee 0.18-0.215-0.25/0.035 |
2* |
Generic |
$20.00 | $40.00 | None |
Norg-ethin estra 0.25-0.035 mg |
2* |
Generic |
$20.00 | $40.00 | None |
NORINYL 1+35-28 TABLET 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$20.00 | $40.00 | None |
Norlyroc 0.35 mg tablet |
2* |
Generic |
$20.00 | $40.00 | None |
NORPACE CR 100MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NORPACE CR 150MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NORTHERA 100 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTHERA 200 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:90 /30Days |
NORTHERA 300 MG CAPSULE |
5 |
Specialty Tier |
29% | 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 |
2* |
Generic |
$20.00 | $40.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$20.00 | $40.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
2* |
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* |
Generic |
$20.00 | $40.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
2* |
Generic |
$20.00 | $40.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
NORTRIPTYLINE HCL 75 MG CAP |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
29% | N/A | P |
NOXAFIL DR 100 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier |
29% | N/A | P |
NUPLAZID 17 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
NUVARING 0.12-0.015 RING VAGINAL |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
NYAMYC 100000 U/G POWDER |
2* |
Generic |
$20.00 | $40.00 | None |
Nyata 100,000 unit/gm powder |
2* |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nystatin 100000[USP'U]/g |
2* |
Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Generic |
$20.00 | $40.00 | None |
Nystatin 100000[USP'U]/mL |
2* |
Generic |
$20.00 | $40.00 | None |
NYSTATIN TABLET 500000U (100 CT) |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
NYSTOP 100000U/GM POWDER |
2* |
Generic |
$20.00 | $40.00 | None |