2017 Medicare Part D Plan Formulary Information |
CenterLight Healthcare Direct Complete Plan (HMO SNP) (H5989-002-0)
Benefit Details
|
The CenterLight Healthcare Direct Complete Plan (HMO SNP) (H5989-002-0) Formulary Drugs Starting with the Letter N in Westchester County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $38.10 Deductible: $400 |
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 |
1* |
Generic |
$9.00 | N/A | None |
Nabumetone 750 mg tablet |
1* |
Generic |
$9.00 | N/A | None |
NADOLOL 20MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NADOLOL 40MG TABLETS |
1* |
Generic |
$9.00 | N/A | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
NADOLOL-BENDROFLU 40-5 MG TAB |
1* |
Generic |
$9.00 | N/A | None |
NADOLOL-BENDROFLU 80-5 MG TAB |
1* |
Generic |
$9.00 | N/A | None |
Nafcillin 1 gm vial |
1* |
Generic |
$9.00 | N/A | None |
Nafcillin 10g/100mL |
1* |
Generic |
$9.00 | N/A | None |
NAGLAZYME 5MG/5ML VIAL |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NALOXONE 0.4 MG/ML VIAL |
1* |
Generic |
$9.00 | N/A | None |
naloxone 1 mg/ml syringe |
1* |
Generic |
$9.00 | N/A | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
1* |
Generic |
$9.00 | N/A | None |
NAMENDA XR 14 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
NAMENDA XR 21 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
NAMENDA XR 28 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
NAMENDA XR 7 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | None |
NAMENDA XR TITRATION PACK |
2 |
Tier 2 |
25% | N/A | None |
NAMZARIC 14 MG-10 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | S |
NAMZARIC 21 MG-10 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | S |
NAMZARIC 28 MG-10 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMZARIC 7 MG-10 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | S |
NAMZARIC TITRATION PACK |
2 |
Tier 2 |
25% | N/A | S |
Naproxen 125 mg/5 ml suspen |
1* |
Generic |
$9.00 | N/A | None |
NAPROXEN 250 MG ORAL TABLET |
1* |
Generic |
$9.00 | N/A | None |
Naproxen 375 mg tablet |
1* |
Generic |
$9.00 | N/A | None |
Naproxen 500mg/1 500 TABLET BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
NAPROXEN DR 375 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NAPROXEN DR 500 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
1* |
Generic |
$9.00 | N/A | None |
NAPROXEN SODIUM 550 MG |
1* |
Generic |
$9.00 | N/A | None |
NARATRIPTAN 2.5MG TABLETS |
1* |
Generic |
$9.00 | N/A | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARATRIPTAN HCL 1 MG TABLET |
1* |
Generic |
$9.00 | N/A | Q:18 /30Days |
NARCAN 4 MG NASAL SPRAY |
2 |
Tier 2 |
25% | N/A | Q:2 /2Days |
NATACYN EYE DROPS |
2 |
Tier 2 |
25% | N/A | None |
Natazia 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
2 |
Tier 2 |
25% | N/A | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
Nateglinide 60mg/1 90 TABLET BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
NATPARA 100 MCG DOSE CARTRIDGE |
2 |
Tier 2 |
25% | N/A | P |
NATPARA 25 MCG DOSE CARTRIDGE |
2 |
Tier 2 |
25% | N/A | P |
NATPARA 50 MCG DOSE CARTRIDGE |
2 |
Tier 2 |
25% | N/A | P |
NATPARA 75 MCG DOSE CARTRIDGE |
2 |
Tier 2 |
25% | N/A | P |
NEBUPENT 300MG INHAL POWDER |
2 |
Tier 2 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Necon 0.5-35-28 tablet |
1* |
Generic |
$9.00 | N/A | None |
NECON 1-50-28 TABLET |
1* |
Generic |
$9.00 | N/A | None |
NECON 10/11-28 TABLET |
1* |
Generic |
$9.00 | N/A | None |
NECON 7-7-7-28 TABLET |
1* |
Generic |
$9.00 | N/A | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
2 |
Tier 2 |
25% | N/A | None |
NEFAZODONE HCL 250MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NEFAZODONE HCL 50MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
2 |
Tier 2 |
25% | N/A | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
2 |
Tier 2 |
25% | N/A | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
1* |
Generic |
$9.00 | N/A | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE |
1* |
Generic |
$9.00 | N/A | 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 |
1* |
Generic |
$9.00 | N/A | None |
NEOMYCIN SULFATE 500MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
1* |
Generic |
$9.00 | N/A | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
1* |
Generic |
$9.00 | N/A | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
1* |
Generic |
$9.00 | N/A | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
1* |
Generic |
$9.00 | N/A | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
1* |
Generic |
$9.00 | N/A | None |
NEPHRAMINE SOLUTION FOR INJECTION |
2 |
Tier 2 |
25% | N/A | P |
NEULASTA 6MG/0.6ML SYRINGE |
2 |
Tier 2 |
25% | N/A | None |
NEUPRO 1 MG/24 HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
NEUPRO 2 MG/24 HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 3 MG/24 HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
NEUPRO 4 MG/24 HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
NEUPRO 6 MG/24 HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
NEUPRO 8 MG/24 HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
NEVANAC 0.1% DROPTAINER |
2 |
Tier 2 |
25% | N/A | None |
nevirapine 200 mg tablet |
1* |
Generic |
$9.00 | N/A | None |
NEVIRAPINE 50 MG/5 ML SUSP |
2 |
Tier 2 |
25% | N/A | None |
NEVIRAPINE ER 100 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NEVIRAPINE ER 400 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NEXAVAR TABLETS 200MG 120 BOT |
2 |
Tier 2 |
25% | N/A | P |
Nexterone 150mg/100mL 100 mL in 1 BAG |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nexterone 360mg/200mL 200 mL in 1 BAG |
2 |
Tier 2 |
25% | N/A | None |
NIACIN ER 1,000 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIACIN ER 500 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIACIN ER 750 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIACOR 500MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
Nicardipine 25 mg/10 ml vial |
1* |
Generic |
$9.00 | N/A | None |
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES |
1* |
Generic |
$9.00 | N/A | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
1* |
Generic |
$9.00 | N/A | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
2 |
Tier 2 |
25% | N/A | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
2 |
Tier 2 |
25% | N/A | None |
Nifedipine 10mg/1 100 CAPSULE BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDIPINE 20MG CAPSULE |
1* |
Generic |
$9.00 | N/A | None |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
1* |
Generic |
$9.00 | N/A | None |
NIFEDIPINE ER 30 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIFEDIPINE ER 30 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIFEDIPINE ER 60 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIFEDIPINE ER 60 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NIFEDIPINE ER 90 MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
Nikki 3 mg-0.02 mg tablet |
1* |
Generic |
$9.00 | N/A | None |
NILANDRON 150 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
Nilutamide 150 mg tablet [Nilandron] |
1* |
Generic |
$9.00 | N/A | None |
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK |
1* |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NINLARO 2.3 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
NINLARO 3 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
NINLARO 4 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1* |
Generic |
$9.00 | N/A | None |
NISOLDIPINE 20MG TB24 |
1* |
Generic |
$9.00 | N/A | None |
NISOLDIPINE 30MG TB24 |
1* |
Generic |
$9.00 | N/A | None |
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1* |
Generic |
$9.00 | N/A | None |
NISOLDIPINE 40MG TB24 |
1* |
Generic |
$9.00 | N/A | None |
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1* |
Generic |
$9.00 | N/A | None |
NITRO-DUR 0.3 MG/HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
NITRO-DUR 0.8 MG/HR PATCH |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin 25mg/5mL |
1* |
Generic |
$9.00 | N/A | None |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
1* |
Generic |
$9.00 | N/A | None |
Nitrofurantoin mcr 100 mg cap |
1* |
Generic |
$9.00 | N/A | None |
NITROFURANTOIN MCR 25 MG CAP |
1* |
Generic |
$9.00 | N/A | None |
NITROFURANTOIN MONO-MCR 100 MG |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN .2MG/HR PATCH |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN .4MG/HR PATCH |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN .6MG/HR PATCH |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN 0.3 MG TABLET SL |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN 0.4 MG TABLET SL |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN 0.6 MG TABLET SL |
1* |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN LINGUAL 0.4 MG |
1* |
Generic |
$9.00 | N/A | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
1* |
Generic |
$9.00 | N/A | None |
NITROSTAT 0.3MG TABLET SL |
2 |
Tier 2 |
25% | N/A | None |
NITROSTAT 0.4MG TABLET SL |
2 |
Tier 2 |
25% | N/A | None |
NITROSTAT 0.6MG TABLET SL |
2 |
Tier 2 |
25% | N/A | None |
NIZATIDINE 15 MG/ML SOLUTION |
1* |
Generic |
$9.00 | N/A | None |
Nizatidine 150mg/1 60 CAPSULE in 1 BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
1* |
Generic |
$9.00 | N/A | None |
NORA-BE 0.35MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
2 |
Tier 2 |
25% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
2 |
Tier 2 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
2 |
Tier 2 |
25% | N/A | P |
NORDITROPIN FLEXPRO 30 MG/3 ML |
2 |
Tier 2 |
25% | N/A | P |
noret-estr-fe 0.4-0.035(21)-75 |
1* |
Generic |
$9.00 | N/A | None |
Norethin-Estrad-Ferr 0.8-0.025 MG |
1* |
Generic |
$9.00 | N/A | None |
Norethin-Estrad-Ferr 1-0.02 mg |
1* |
Generic |
$9.00 | N/A | None |
NORETHIN-ETH ESTRAD 0.5-2.5 |
1* |
Generic |
$9.00 | N/A | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG |
1* |
Generic |
$9.00 | N/A | None |
norethind-eth estrad 1-0.02 mg |
1* |
Generic |
$9.00 | N/A | None |
Norethindrone 0.35 mg tablet |
1* |
Generic |
$9.00 | N/A | None |
NORETHINDRONE 5MG TABLET |
1* |
Generic |
$9.00 | N/A | None |
NORG-EE 0.18-0.215-0.25/0.025 |
1* |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
norg-ee 0.18-0.215-0.25/0.035 |
1* |
Generic |
$9.00 | N/A | None |
Norg-ethin estra 0.25-0.035 mg |
1* |
Generic |
$9.00 | N/A | None |
Norlyroc 0.35 mg tablet |
1* |
Generic |
$9.00 | N/A | None |
NORMOSOL -R INJ /D5W |
2 |
Tier 2 |
25% | N/A | None |
NORMOSOL-M AND DEXTROSE 5% |
1* |
Generic |
$9.00 | N/A | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
2 |
Tier 2 |
25% | N/A | None |
NORPACE CR 100MG CAPSULE SA |
2 |
Tier 2 |
25% | N/A | None |
NORPACE CR 150MG CAPSULE SA |
2 |
Tier 2 |
25% | N/A | None |
NORTHERA 100 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
NORTHERA 200 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
NORTHERA 300 MG CAPSULE |
2 |
Tier 2 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
1* |
Generic |
$9.00 | N/A | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1* |
Generic |
$9.00 | N/A | None |
NORTREL 1-0.035MG TABLET 28DAY |
1* |
Generic |
$9.00 | N/A | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER |
1* |
Generic |
$9.00 | N/A | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
1* |
Generic |
$9.00 | N/A | None |
NORTRIPTYLINE HCL 25MG CAP |
1* |
Generic |
$9.00 | N/A | None |
NORTRIPTYLINE HCL 75 MG CAP |
1* |
Generic |
$9.00 | N/A | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE |
1* |
Generic |
$9.00 | N/A | None |
NORVIR 100 MG TABLET |
2 |
Tier 2 |
25% | N/A | None |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 80MG/ML ORAL SOLUTION |
2 |
Tier 2 |
25% | N/A | None |
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Tier 2 |
25% | N/A | None |
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Tier 2 |
25% | N/A | None |
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
2 |
Tier 2 |
25% | N/A | None |
NOVOLOG 100 UNIT/ML CARTRIDGE |
2 |
Tier 2 |
25% | N/A | None |
NOVOLOG 100U/ML VIAL |
2 |
Tier 2 |
25% | N/A | None |
NOVOLOG FLEXPEN SYRINGE |
2 |
Tier 2 |
25% | N/A | None |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
2 |
Tier 2 |
25% | N/A | None |
NOVOLOG MIX 70/30 VIAL |
2 |
Tier 2 |
25% | N/A | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
2 |
Tier 2 |
25% | N/A | P |
NOXAFIL DR 100 MG TABLET |
2 |
Tier 2 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUCALA 100 MG VIAL |
2 |
Tier 2 |
25% | N/A | P |
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
NUEDEXTA 20; 10mg/1; mg/1 |
2 |
Tier 2 |
25% | N/A | Q:60 /30Days |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
2 |
Tier 2 |
25% | N/A | P |
NUPLAZID 17 MG TABLET |
2 |
Tier 2 |
25% | N/A | P |
NUTRILIPID 20 % EMULSION |
1* |
Generic |
$9.00 | N/A | P |
NUVARING 0.12-0.015 RING VAGINAL |
2 |
Tier 2 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUVIGIL 200 MG TABLET |
2 |
Tier 2 |
25% | N/A | P Q:30 /30Days |
NYAMYC 100000 U/G POWDER |
1* |
Generic |
$9.00 | N/A | None |
Nyata 100,000 unit/gm powder |
1* |
Generic |
$9.00 | N/A | None |
Nystatin 100000[USP'U]/g |
1* |
Generic |
$9.00 | N/A | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1* |
Generic |
$9.00 | N/A | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1* |
Generic |
$9.00 | N/A | None |
Nystatin 100000[USP'U]/mL |
1* |
Generic |
$9.00 | N/A | None |
NYSTATIN TABLET 500000U (100 CT) |
1* |
Generic |
$9.00 | N/A | None |
NYSTOP 100000U/GM POWDER |
1* |
Generic |
$9.00 | N/A | None |