2019 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Value (PDP) (S7126-044-0)
Benefit Details
|
The Mutual of Omaha Rx Value (PDP) (S7126-044-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $28.80 Deductible: $415 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 10 GM BULK VIAL |
5 |
Specialty Tier |
25% | N/A | None |
NAFCILLIN 2 GM VIAL |
4 |
Non-Preferred Drug |
35% | N/A | None |
NAFTIFINE HCL 1% CREAM (g) [Naftin-MP] |
3 |
Preferred Brand |
15% | 18% | Q:60 /28Days |
NAFTIFINE HCL 2% CREAM [Naftin] |
3 |
Preferred Brand |
15% | 18% | Q:60 /28Days |
NALOXONE 0.4 MG/ML CARPUJECT |
2* |
Generic |
$4.00 | $8.00 | None |
NALOXONE 0.4 MG/ML VIAL |
2* |
Generic |
$4.00 | $8.00 | None |
naloxone 1 mg/ml syringe |
2* |
Generic |
$4.00 | $8.00 | None |
NALTREXONE 50 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
NAMENDA 5-10MG TITRATION PK |
3 |
Preferred Brand |
15% | 18% | P |
NAMZARIC 14 MG-10 MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMZARIC 21 MG-10 MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P |
NAMZARIC 28 MG-10 MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P |
NAMZARIC 7 MG-10 MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P |
NAMZARIC TITRATION PACK |
3 |
Preferred Brand |
15% | 18% | P |
Naproxen 125 mg/5 ml suspen |
2* |
Generic |
$4.00 | $8.00 | None |
NAPROXEN 250 MG ORAL TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
NAPROXEN 375 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
NAPROXEN 500 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
NARCAN 4 MG NASAL SPRAY |
3 |
Preferred Brand |
15% | 18% | None |
NATACYN EYE DROPS |
3 |
Preferred Brand |
15% | 18% | None |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
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% | N/A | P Q:2 /28Days |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
NATROBA 0.9% TOPICAL SUSP |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
15% | 18% | P Q:1 /28Days |
NEFAZODONE HCL 150MG TABLET (60 CT) |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEFAZODONE HCL 250MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEFAZODONE HCL 50MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYC-POLYM-DEXAMET EYE OINTM [Poly-Dex] |
2* |
Generic |
$4.00 | $8.00 | None |
NEOMYC-POLYM-DEXAMETH EYE DROP |
2* |
Generic |
$4.00 | $8.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2* |
Generic |
$4.00 | $8.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2* |
Generic |
$4.00 | $8.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
3 |
Preferred Brand |
15% | 18% | P |
NERLYNX 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
NEULASTA 6MG/0.6ML SYRINGE |
4 |
Non-Preferred Drug |
35% | N/A | P |
NEUPOGEN 300 MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
25% | N/A | P |
NEUPRO 1 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEUPRO 2 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEUPRO 3 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEUPRO 4 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEUPRO 6 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEUPRO 8 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
35% | N/A | None |
NEVIRAPINE 200 MG TABLET |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
NEVIRAPINE 50 MG/5 ML SUSP Oral Suspension [Viramune] |
3 |
Preferred Brand |
15% | 18% | 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 Drug |
35% | N/A | Q:90 /30Days |
NEVIRAPINE ER 400 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | Q:30 /30Days |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
NIACIN ER 1,000 MG TABLET [Niaspan ER] |
4 |
Non-Preferred Drug |
35% | N/A | None |
NIACIN ER 500 MG TABLET [Niaspan ER] |
4 |
Non-Preferred Drug |
35% | N/A | None |
NIACIN ER 750 MG TABLET [Niaspan ER] |
4 |
Non-Preferred Drug |
35% | N/A | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
4 |
Non-Preferred Drug |
35% | N/A | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
4 |
Non-Preferred Drug |
35% | N/A | None |
NIFEDIPINE ER 30 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
NIFEDIPINE ER 30 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
NIFEDIPINE ER 60 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDIPINE ER 60 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
NIFEDIPINE ER 90 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
NIFEDIPINE ER 90 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
NILUTAMIDE 150 MG TABLET [Nilandron] |
5 |
Specialty Tier |
25% | N/A | None |
NIMODIPINE 30 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | None |
NINLARO 2.3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
NINLARO 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
NINLARO 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
NITRO-BID 2% OINTMENT |
2* |
Generic |
$4.00 | $8.00 | None |
Nitrofurantoin 25mg/5mL |
3 |
Preferred Brand |
15% | 18% | None |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin] |
3 |
Preferred Brand |
15% | 18% | None |
NITROFURANTOIN MCR 25 MG CAP |
3 |
Preferred Brand |
15% | 18% | None |
NITROFURANTOIN MONO-MCR 100 MG CAPSULE [Macrobid] |
4 |
Non-Preferred Drug |
35% | N/A | None |
NITROGLYCERIN 0.2 MG/HR PATCH |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN 0.3 MG TABLET SL |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN 0.4 MG TABLET SL |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN 0.4 MG/HR PATCH |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN 0.6 MG TABLET SL |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN 0.6 MG/HR PATCH |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN LINGUAL 0.4 MG |
2* |
Generic |
$4.00 | $8.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P |
noret-estr-fe 0.4-0.035(21)-75 |
4 |
Non-Preferred Drug |
35% | N/A | None |
NORETH-ESTRAD-FE 1-0.02(24)-75 Chewable TABLET [Minastrin] |
4 |
Non-Preferred Drug |
35% | N/A | None |
Norethin-Estrad-Ferr 0.8-0.025 MG |
4 |
Non-Preferred Drug |
35% | N/A | None |
Norethin-Estrad-Ferr 1-0.02 mg |
4 |
Non-Preferred Drug |
35% | N/A | None |
NORETHIN-ETH ESTRAD 0.5-2.5 |
4 |
Non-Preferred Drug |
35% | N/A | P |
NORETHIND-ETH ESTRAD 1-0.02 MG |
4 |
Non-Preferred Drug |
35% | N/A | None |
NORETHINDRONE 0.35 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
NORETHINDRONE 5MG TABLET |
4 |
Non-Preferred Drug |
35% | 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 |
4 |
Non-Preferred Drug |
35% | N/A | None |
NORG-ETHIN ESTRA 0.18-0.215-0.25/0.025 |
4 |
Non-Preferred Drug |
35% | N/A | None |
NORG-ETHIN ESTRA 0.25-0.035 MG |
4 |
Non-Preferred Drug |
35% | N/A | None |
NORMOSOL -R INJ /D5W |
3 |
Preferred Brand |
15% | 18% | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
3 |
Preferred Brand |
15% | 18% | None |
NORTHERA 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
NORTHERA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
NORTHERA 300 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
NORTRIPTYLINE 10 MG/5 ML SOL |
2* |
Generic |
$4.00 | $8.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
2* |
Generic |
$4.00 | $8.00 | None |
NORTRIPTYLINE HCL 50 MG CAP |
2* |
Generic |
$4.00 | $8.00 | 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 |
$4.00 | $8.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
NORVIR 100 MG POWDER PACKET |
3 |
Preferred Brand |
15% | 18% | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
15% | 18% | Q:450 /30Days |
NOVOLOG 100 UNIT/ML CARTRIDGE |
4 |
Non-Preferred Drug |
35% | N/A | S |
NOVOLOG 100U/ML VIAL |
4 |
Non-Preferred Drug |
35% | N/A | S |
NOVOLOG FLEXPEN SYRINGE |
4 |
Non-Preferred Drug |
35% | N/A | S |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
4 |
Non-Preferred Drug |
35% | N/A | S |
NOVOLOG MIX 70/30 VIAL |
4 |
Non-Preferred Drug |
35% | N/A | S |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
25% | N/A | Q:840 /30Days |
NOXAFIL DR 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:93 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Preferred Brand |
15% | 18% | P |
NUPLAZID 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
NUPLAZID 34 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
NYAMYC 100,000 UNITS/GM POWDER |
4 |
Non-Preferred Drug |
35% | N/A | None |
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF] |
2* |
Generic |
$4.00 | $8.00 | Q:30 /28Days |
NYSTATIN 100,000 UNIT/GM POWD |
2* |
Generic |
$4.00 | $8.00 | None |
NYSTATIN 100,000 UNITS/GM OINT |
2* |
Generic |
$4.00 | $8.00 | Q:30 /28Days |
Nystatin 100000[USP'U]/mL |
2* |
Generic |
$4.00 | $8.00 | None |
NYSTATIN 500,000 UNIT ORAL TAB |
2* |
Generic |
$4.00 | $8.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /28Days |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTOP 100,000 UNITS/GM POWDER |
4 |
Non-Preferred Drug |
35% | N/A | None |