2018 Medicare Part D Plan Formulary Information |
AARP MedicareRx Saver Plus (PDP) (S5921-375-0)
Benefit Details
|
The AARP MedicareRx Saver Plus (PDP) (S5921-375-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $53.10 Deductible: $405 Qualifies for LIS: No |
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 |
Nafcillin 1 gm vial |
4 |
Non-Preferred Drug |
41% | 41% | None |
NAFCILLIN 10 GM BULK VIAL |
4 |
Non-Preferred Drug |
41% | 41% | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Drug |
41% | 41% | None |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Drug |
41% | 41% | None |
NALOXONE 0.4 MG/ML CARPUJECT |
4 |
Non-Preferred Drug |
41% | 41% | None |
NALOXONE 0.4 MG/ML VIAL |
4 |
Non-Preferred Drug |
41% | 41% | None |
naloxone 1 mg/ml syringe |
4 |
Non-Preferred Drug |
41% | 41% | None |
NALTREXONE 50 MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NAMENDA XR 14 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA XR 21 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMENDA XR 28 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMENDA XR TITRATION PACK |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMZARIC 14 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMZARIC 21 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMZARIC 28 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMZARIC 7 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:30 /30Days |
NAMZARIC TITRATION PACK |
3 |
Preferred Brand |
$29.00 | $82.00 | P Q:28 /28Days |
Naproxen 125 mg/5 ml suspen |
2 |
Generic |
$8.00 | $0.00 | None |
NAPROXEN 250 MG ORAL TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 375 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NAPROXEN 500 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NAPROXEN DR 375 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NAPROXEN DR 500 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NARATRIPTAN HCL 1 MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | Q:12 /30Days |
NARATRIPTAN HCL 2.5 MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | Q:12 /30Days |
NARCAN 4 MG NASAL SPRAY |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NATACYN EYE DROPS |
4 |
Non-Preferred Drug |
41% | 41% | None |
NATEGLINIDE 120 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | Q:90 /30Days |
NATEGLINIDE 60 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | Q:180 /30Days |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NATPARA 25 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
NEBUPENT 300MG INHAL POWDER |
4 |
Non-Preferred Drug |
41% | 41% | P Q:1 /28Days |
NECON 0.5-35-28 TABLET |
4 |
Non-Preferred Drug |
41% | 41% | None |
NECON 7-7-7-28 TABLET |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEFAZODONE HCL 250MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEFAZODONE HCL 50MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEOMYC-POLYM-DEXAMET EYE OINTM [Poly-Dex] |
2 |
Generic |
$8.00 | $0.00 | None |
NEOMYC-POLYM-DEXAMETH EYE DROP |
2 |
Generic |
$8.00 | $0.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEOMYCIN/POLY AMP 10X1 ML |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Non-Preferred Drug |
41% | 41% | P |
NERLYNX 40 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
NEUPRO 1 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEUPRO 2 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEUPRO 3 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEUPRO 4 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEUPRO 6 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEUPRO 8 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
41% | 41% | None |
NEVIRAPINE 200 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | Q:90 /30Days |
NEVIRAPINE ER 100 MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | Q:90 /30Days |
NEVIRAPINE ER 400 MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | Q:60 /30Days |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIACOR 500 MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NICARDIPINE 25 MG/10 ML VIAL |
4 |
Non-Preferred Drug |
41% | 41% | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
4 |
Non-Preferred Drug |
41% | 41% | None |
NIKKI 3 MG-0.02 MG TABLET |
4 |
Non-Preferred Drug |
41% | 41% | None |
NILUTAMIDE 150 MG TABLET [Nilandron] |
5 |
Specialty Tier |
25% | 25% | None |
NIMODIPINE 30 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
NINLARO 2.3 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:3 /28Days |
NINLARO 3 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:3 /28Days |
NINLARO 4 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:3 /28Days |
NIPENT FOR INJECTION 10MG VIALS |
5 |
Specialty Tier |
25% | 25% | None |
NITRO-BID 2% OINTMENT |
4 |
Non-Preferred Drug |
41% | 41% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin 25mg/5mL |
4 |
Non-Preferred Drug |
41% | 41% | None |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
Nitrofurantoin mcr 100 mg cap |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROFURANTOIN MONO-MCR 100 MG |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROGLYCERIN 0.2 MG/HR PATCH |
2 |
Generic |
$8.00 | $0.00 | None |
NITROGLYCERIN 0.3 MG TABLET SL |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROGLYCERIN 0.4 MG TABLET SL |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROGLYCERIN 0.4 MG/HR PATCH |
2 |
Generic |
$8.00 | $0.00 | None |
NITROGLYCERIN 0.6 MG TABLET SL |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROGLYCERIN 0.6 MG/HR PATCH |
2 |
Generic |
$8.00 | $0.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
41% | 41% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN LINGUAL 0.4 MG |
4 |
Non-Preferred Drug |
41% | 41% | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2 |
Generic |
$8.00 | $0.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROSTAT 0.4 MG TABLET SL [Nitrotab] |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NIZATIDINE 150 MG CAPSULE |
2 |
Generic |
$8.00 | $0.00 | None |
NIZATIDINE 300 MG CAPSULE |
2 |
Generic |
$8.00 | $0.00 | None |
NORA-BE 0.35MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
noret-estr-fe 0.4-0.035(21)-75 |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORETH-ESTRAD-FE 1-0.02(24)-75 Chewable Tablet [Minastrin] |
4 |
Non-Preferred Drug |
41% | 41% | None |
Norethin-Estrad-Ferr 0.8-0.025 MG |
4 |
Non-Preferred Drug |
41% | 41% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Norethin-Estrad-Ferr 1-0.02 mg |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NORETHIND-ETH ESTRAD 1-0.02 MG |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORETHINDRONE 0.35 MG TABLET |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Generic |
$8.00 | $0.00 | None |
NORG-EE 0.18-0.215-0.25/0.035 |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORG-ETHIN ESTRA 0.18-0.215-0.25/0.025 |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORG-ETHIN ESTRA 0.25-0.035 MG |
4 |
Non-Preferred Drug |
41% | 41% | None |
Norlyroc 0.35 mg tablet |
3 |
Preferred Brand |
$29.00 | $82.00 | None |
NORMOSOL -R INJ /D5W |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Non-Preferred Drug |
41% | 41% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORTHERA 100 MG CAPSULE |
4 |
Non-Preferred Drug |
41% | 41% | P Q:90 /30Days |
NORTHERA 200 MG CAPSULE |
4 |
Non-Preferred Drug |
41% | 41% | P Q:180 /30Days |
NORTHERA 300 MG CAPSULE |
4 |
Non-Preferred Drug |
41% | 41% | 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 Drug |
41% | 41% | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
41% | 41% | None |
NORTREL 1-0.035MG TABLET 28DAY |
4 |
Non-Preferred Drug |
41% | 41% | 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 Drug |
41% | 41% | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
2 |
Generic |
$8.00 | $0.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
2 |
Generic |
$8.00 | $0.00 | None |
NORTRIPTYLINE HCL 50 MG CAP |
2 |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTRIPTYLINE HCL 75 MG CAP |
2 |
Generic |
$8.00 | $0.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$8.00 | $0.00 | None |
NORVIR 100 MG POWDER PACKET |
4 |
Non-Preferred Drug |
41% | 41% | Q:540 /30Days |
NORVIR 100 MG TABLET |
4 |
Non-Preferred Drug |
41% | 41% | Q:540 /30Days |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
41% | 41% | Q:540 /30Days |
NORVIR 80MG/ML ORAL SOLUTION |
4 |
Non-Preferred Drug |
41% | 41% | Q:720 /30Days |
novarel 10,000 units vial |
4 |
Non-Preferred Drug |
41% | 41% | P |
NOVAREL 5,000 UNIT VIAL |
4 |
Non-Preferred Drug |
41% | 41% | P |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
25% | 25% | Q:600 /30Days |
NOXAFIL DR 100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:240 /30Days |
NUCALA 100 MG VIAL |
5 |
Specialty Tier |
25% | 25% | P Q:3 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUEDEXTA 20; 10mg/1; mg/1 |
4 |
Non-Preferred Drug |
41% | 41% | P |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier |
25% | 25% | P |
NUPLAZID 17 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
NUTRILIPID 20 % EMULSION |
4 |
Non-Preferred Drug |
41% | 41% | P |
NUVARING 0.12-0.015 RING VAGINAL |
4 |
Non-Preferred Drug |
41% | 41% | None |
NYAMYC 100,000 UNITS/GM POWDER |
2 |
Generic |
$8.00 | $0.00 | None |
NYMALIZE 30 MG/10 ML SOLUTION |
5 |
Specialty Tier |
25% | 25% | None |
NYSTATIN 100,000 UNIT/GM CREAM |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
NYSTATIN 100,000 UNIT/GM POWD |
2 |
Generic |
$8.00 | $0.00 | None |
NYSTATIN 100,000 UNITS/GM OINT |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Nystatin 100000[USP'U]/mL |
2 |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN 500,000 UNIT ORAL TAB |
2 |
Generic |
$8.00 | $0.00 | None |
NYSTOP 100,000 UNITS/GM POWDER |
2 |
Generic |
$8.00 | $0.00 | None |