2019 Medicare Part D Plan Formulary Information |
Magellan Rx Medicare Basic (PDP) (S4607-009-0)
Benefit Details
|
The Magellan Rx Medicare Basic (PDP) (S4607-009-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 7 which includes: VA Plan Monthly Premium: $28.70 Deductible: $415 Qualifies for LIS: Yes |
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 |
$2.00 | $5.00 | None |
NABUMETONE 750 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
Nafcillin 1 gm vial |
4 |
Non-Preferred Drug |
45% | 45% | None |
NAFCILLIN 10 GM BULK VIAL |
5 |
Specialty Tier |
25% | N/A | None |
NAFCILLIN 2 GM VIAL |
4 |
Non-Preferred Drug |
45% | 45% | None |
NALOXONE 0.4 MG/ML CARPUJECT |
2 |
Generic |
$2.00 | $5.00 | None |
NALOXONE 0.4 MG/ML VIAL |
2 |
Generic |
$2.00 | $5.00 | None |
naloxone 1 mg/ml syringe |
2 |
Generic |
$2.00 | $5.00 | None |
NALTREXONE 50 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
Naproxen 125 mg/5 ml suspen |
2 |
Generic |
$2.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 250 MG ORAL TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NAPROXEN 375 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
NAPROXEN 500 MG TABLET |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
NARCAN 4 MG NASAL SPRAY |
4 |
Non-Preferred Drug |
45% | 45% | None |
NATACYN EYE DROPS |
4 |
Non-Preferred Drug |
45% | 45% | None |
NATEGLINIDE 120 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NATEGLINIDE 60 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEBUPENT 300MG INHAL POWDER |
4 |
Non-Preferred Drug |
45% | 45% | P |
NECON 0.5-35-28 TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEFAZODONE HCL 250MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEFAZODONE HCL 50MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEOMYC-POLYM-DEXAMET EYE OINTM [Poly-Dex] |
2 |
Generic |
$2.00 | $5.00 | None |
NEOMYC-POLYM-DEXAMETH EYE DROP |
2 |
Generic |
$2.00 | $5.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
2 |
Generic |
$2.00 | $5.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
3 |
Preferred Brand |
19% | 19% | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2 |
Generic |
$2.00 | $5.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Non-Preferred Drug |
45% | 45% | P |
NERLYNX 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300 MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | N/A | None |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 1 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
45% | 45% | S |
NEUPRO 2 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
45% | 45% | S |
NEUPRO 3 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
45% | 45% | S |
NEUPRO 4 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
45% | 45% | S |
NEUPRO 6 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
45% | 45% | S |
NEUPRO 8 MG/24 HR PATCH |
4 |
Non-Preferred Drug |
45% | 45% | S |
NEVIRAPINE 200 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NEVIRAPINE 50 MG/5 ML SUSP Oral Suspension [Viramune] |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEVIRAPINE ER 100 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEVIRAPINE ER 400 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIACOR 500 MG TABLET |
3 |
Preferred Brand |
19% | 19% | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
19% | 19% | Q:360 /365Days |
NIFEDIPINE ER 30 MG TABLET |
3 |
Preferred Brand |
19% | 19% | None |
NIFEDIPINE ER 60 MG TABLET |
3 |
Preferred Brand |
19% | 19% | None |
NIFEDIPINE ER 90 MG TABLET |
3 |
Preferred Brand |
19% | 19% | None |
NIKKI 3 MG-0.02 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NILUTAMIDE 150 MG TABLET [Nilandron] |
5 |
Specialty Tier |
25% | N/A | None |
NIMODIPINE 30 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
NINLARO 2.3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
NINLARO 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
NINLARO 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITRO-BID 2% OINTMENT |
4 |
Non-Preferred Drug |
45% | 45% | None |
Nitrofurantoin 25mg/5mL |
4 |
Non-Preferred Drug |
45% | 45% | Q:7200 /365Days |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
3 |
Preferred Brand |
19% | 19% | Q:720 /365Days |
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin] |
3 |
Preferred Brand |
19% | 19% | Q:360 /365Days |
NITROFURANTOIN MCR 25 MG CAP |
3 |
Preferred Brand |
19% | 19% | Q:1440 /365Days |
NITROFURANTOIN MONO-MCR 100 MG CAPSULE [Macrobid] |
3 |
Preferred Brand |
19% | 19% | Q:180 /365Days |
NITROGLYCERIN 0.2 MG/HR PATCH |
3 |
Preferred Brand |
19% | 19% | None |
NITROGLYCERIN 0.3 MG TABLET SL |
3 |
Preferred Brand |
19% | 19% | None |
NITROGLYCERIN 0.4 MG TABLET SL |
3 |
Preferred Brand |
19% | 19% | None |
NITROGLYCERIN 0.4 MG/HR PATCH |
3 |
Preferred Brand |
19% | 19% | None |
NITROGLYCERIN 0.6 MG TABLET SL |
3 |
Preferred Brand |
19% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN 0.6 MG/HR PATCH |
3 |
Preferred Brand |
19% | 19% | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
3 |
Preferred Brand |
19% | 19% | None |
NIZATIDINE 15 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
NIZATIDINE 150 MG CAPSULE |
2 |
Generic |
$2.00 | $5.00 | None |
NIZATIDINE 300 MG CAPSULE |
2 |
Generic |
$2.00 | $5.00 | None |
NORA-BE 0.35MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
noret-estr-fe 0.4-0.035(21)-75 |
2 |
Generic |
$2.00 | $5.00 | None |
Norethin-Estrad-Ferr 0.8-0.025 MG |
2 |
Generic |
$2.00 | $5.00 | None |
Norethin-Estrad-Ferr 1-0.02 mg |
2 |
Generic |
$2.00 | $5.00 | None |
NORETHIN-ETH ESTRAD 0.5-2.5 |
4 |
Non-Preferred Drug |
45% | 45% | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG |
4 |
Non-Preferred Drug |
45% | 45% | 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 |
2 |
Generic |
$2.00 | $5.00 | None |
NORETHINDRONE 0.35 MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Generic |
$2.00 | $5.00 | None |
NORG-EE 0.18-0.215-0.25/0.035 |
2 |
Generic |
$2.00 | $5.00 | None |
NORG-ETHIN ESTRA 0.18-0.215-0.25/0.025 |
2 |
Generic |
$2.00 | $5.00 | None |
NORG-ETHIN ESTRA 0.25-0.035 MG |
2 |
Generic |
$2.00 | $5.00 | None |
Norlyroc 0.35 mg tablet |
2 |
Generic |
$2.00 | $5.00 | None |
NORMOSOL -R INJ /D5W |
4 |
Non-Preferred Drug |
45% | 45% | None |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Non-Preferred Drug |
45% | 45% | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
NORTHERA 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTHERA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
NORTHERA 300 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
2 |
Generic |
$2.00 | $5.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
2 |
Generic |
$2.00 | $5.00 | 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 |
$2.00 | $5.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
2 |
Generic |
$2.00 | $5.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
2 |
Generic |
$2.00 | $5.00 | None |
NORTRIPTYLINE HCL 50 MG CAP |
2 |
Generic |
$2.00 | $5.00 | None |
NORTRIPTYLINE HCL 75 MG CAP |
2 |
Generic |
$2.00 | $5.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$2.00 | $5.00 | None |
NORVIR 100 MG POWDER PACKET |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 100 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
NORVIR 80MG/ML ORAL SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
25% | N/A | None |
NOXAFIL DR 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
NUCALA 100 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
NUEDEXTA 20; 10mg/1; mg/1 |
4 |
Non-Preferred Drug |
45% | 45% | P |
NUPLAZID 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
NUPLAZID 34 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
NUTRILIPID 20 % EMULSION |
4 |
Non-Preferred Drug |
45% | 45% | P |
NUVARING 0.12-0.015 RING VAGINAL |
4 |
Non-Preferred Drug |
45% | 45% | None |
NYAMYC 100,000 UNITS/GM POWDER |
3 |
Preferred Brand |
19% | 19% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF] |
3 |
Preferred Brand |
19% | 19% | None |
NYSTATIN 100,000 UNIT/GM POWD |
3 |
Preferred Brand |
19% | 19% | None |
NYSTATIN 100,000 UNITS/GM OINT |
3 |
Preferred Brand |
19% | 19% | None |
Nystatin 100000[USP'U]/mL |
3 |
Preferred Brand |
19% | 19% | None |
NYSTATIN 500,000 UNIT ORAL TAB |
3 |
Preferred Brand |
19% | 19% | None |
NYSTOP 100,000 UNITS/GM POWDER |
3 |
Preferred Brand |
19% | 19% | None |