2020 Medicare Part D Plan Formulary Information |
Blue Shield Vital (HMO) (H0504-045-0)
Benefit Details
|
The Blue Shield Vital (HMO) (H0504-045-0) Formulary Drugs Starting with the Letter N in Riverside County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $0.00 Deductible: $0 |
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 [Relafen] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NABUMETONE 750 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NAFCILLIN 1 GM VIAL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NAFCILLIN 10 GM BULK VIAL |
5 |
Tier 5 |
33% | N/A | None |
NAFCILLIN 2 GM VIAL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NALOXONE 0.4 MG/ML CARPUJECT CARTRIDGE [Narcan] |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /30Days |
NALOXONE 0.4 MG/ML VIAL |
2 |
Tier 2 |
$10.00 | $15.00 | None |
naloxone 1 mg/ml syringe |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NALTREXONE 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NAMZARIC 14 MG-10 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMZARIC 21 MG-10 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:1 /1Days |
NAMZARIC 28 MG-10 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:1 /1Days |
NAMZARIC 7 MG-10 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:1 /1Days |
NAMZARIC TITRATION PACK |
4 |
Tier 4 |
$95.00 | $237.50 | Q:28 /28Days |
NAPROXEN 250 MG TABLET [Naprosyn] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NAPROXEN 375 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NAPROXEN 500 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NAPROXEN DR 375 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NAPROXEN DR 500 MG TABLET DR [EC-Naprosyn] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NARATRIPTAN HCL 1 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | Q:18 /30Days |
NARATRIPTAN HCL 2.5 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NARCAN 4 MG NASAL SPRAY |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /30Days |
NATACYN EYE DROPS |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NATEGLINIDE 120 MG TABLET [Starlix] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:3 /1Days |
NATEGLINIDE 60 MG TABLET [Starlix] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:6 /1Days |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P Q:2 /28Days |
NATPARA 25 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P Q:2 /28Days |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P Q:2 /28Days |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P Q:2 /28Days |
NAYZILAM 5 MG NASAL SPRAY |
5 |
Tier 5 |
33% | N/A | Q:10 /30Days |
NECON 0.5-35-28 TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEFAZODONE HCL 250MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NEFAZODONE HCL 50MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NEOMYC-POLYM-DEXAMET EYE OINTMENT [Poly-Dex] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NEOMYC-POLYM-DEXAMETH EYE DROP |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NERLYNX 40 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:6 /1Days |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
NEUPRO 1 MG/24 HR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
NEUPRO 4 MG/24 HR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
NEUPRO 6 MG/24 HR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
NEVIRAPINE 200 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | Q:2 /1Days |
NEVIRAPINE 50 MG/5 ML SUSP Oral Suspension [Viramune] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:40 /1Days |
NEVIRAPINE ER 100 MG TABLET ER 24H [Viramune XR] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:3 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEVIRAPINE ER 400 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:1 /1Days |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
NIACIN ER 1,000 MG TABLET [Niaspan ER] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
NIACIN ER 500 MG TABLET [Niaspan ER] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:4 /1Days |
NIACIN ER 750 MG TABLET [Niaspan ER] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:2 /1Days |
NIACOR 500 MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Nicardipine hydrochloride 20 MG Oral Capsule |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Nicardipine hydrochloride 30 MG Oral Capsule |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NIFEDIPINE 10 MG CAPSULE [Procardia] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIFEDIPINE 20MG CAPSULE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIFEDIPINE ER 60 MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIFEDIPINE ER 60 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIFEDIPINE ER 90 MG TABLET ER [Nifediac CC] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIFEDIPINE ER 90 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NIKKI 3 MG-0.02 MG TABLET [Yaz] |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NILUTAMIDE 150 MG TABLET [Nilandron] |
5 |
Tier 5 |
33% | N/A | Q:1 /1Days |
NIMODIPINE 30 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NINLARO 2.3 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:3 /21Days |
NINLARO 3 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:3 /21Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NINLARO 4 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:3 /21Days |
NITISINONE 10 MG CAPSULE [Orfadin] |
5 |
Tier 5 |
33% | N/A | P Q:14 /1Days |
NITISINONE 2 MG CAPSULE [Orfadin] |
5 |
Tier 5 |
33% | N/A | P Q:70 /1Days |
NITISINONE 5 MG CAPSULE [Orfadin] |
5 |
Tier 5 |
33% | N/A | P Q:20 /1Days |
NITRO-BID 2% OINTMENT |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROFURANTOIN MCR 25 MG CAP |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROFURANTOIN MONO-MCR 100 MG CAPSULE [Macrobid] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROGLYCERIN 0.2 MG/HR PATCH |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROGLYCERIN 0.3 MG TABLET SL |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN 0.4 MG SUSLIGUAL TABLET [Nitrotab] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROGLYCERIN 0.4 MG/HR PATCH |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROGLYCERIN 0.6 MG SUSLIGUAL TABLET [Nitrotab] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROGLYCERIN 0.6 MG/HR PATCH |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROSTAT 0.4 MG TABLET SL [Nitrotab] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NITYR 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
NITYR 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
NITYR 5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORA-BE 0.35MG TABLET |
3 |
Tier 3 |
$40.00 | $100.00 | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Tier 5 |
33% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Tier 5 |
33% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Tier 5 |
33% | N/A | P |
NORDITROPIN FLEXPRO 30 MG/3 ML |
5 |
Tier 5 |
33% | N/A | P |
noret-estr-fe 0.4-0.035(21)-75 |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG |
4 |
Tier 4 |
$95.00 | $237.50 | P |
NORETHIND-ETH ESTRAD 1-0.02 MG |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORETHINDRONE 0.35 MG TABLET [Sharobel 28-Day] |
3 |
Tier 3 |
$40.00 | $100.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORG-EE 0.18-0.215-0.25/0.035 |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORG-ETHIN ESTRA 0.25-0.035 MG |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Tier 4 |
$95.00 | $237.50 | None |
NORTHERA 100 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:252 /90Days |
NORTHERA 200 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:126 /90Days |
NORTHERA 300 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:84 /90Days |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTRIPTYLINE HCL 50 MG CAP |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORTRIPTYLINE HCL 75 MG CAP |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NORVIR 100 MG POWDER PACKET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:12 /1Days |
NORVIR 80MG/ML ORAL SOLUTION |
4 |
Tier 4 |
$95.00 | $237.50 | Q:15 /1Days |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Tier 5 |
33% | N/A | P |
NUBEQA 300 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
NUCALA 100 MG VIAL |
5 |
Tier 5 |
33% | N/A | P Q:3 /28Days |
NUCALA 100 MG/ML AUTO-INJECTOR AUTO INJCT |
5 |
Tier 5 |
33% | N/A | P Q:3 /28Days |
NUCALA 100 MG/ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P Q:3 /28Days |
NUPLAZID 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NUPLAZID 34 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
NUTRILIPID 20 % EMULSION |
4 |
Tier 4 |
$95.00 | $237.50 | P |
NYAMYC 100,000 UNITS/GM POWDER |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NYMALIZE 60 MG/10 ML ORAL SYRINGE |
5 |
Tier 5 |
33% | N/A | Q:1260 /21Days |
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NYSTATIN 100,000 UNIT/GM OINTMENT [Nystex] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NYSTATIN 100,000 UNIT/GM POWDER [Pedi-Dri] |
2 |
Tier 2 |
$10.00 | $15.00 | None |
Nystatin 100000[USP'U]/mL |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NYSTATIN 500,000 UNIT ORAL TAB |
2 |
Tier 2 |
$10.00 | $15.00 | None |
NYSTOP 100,000 UNITS/GM POWDER |
2 |
Tier 2 |
$10.00 | $15.00 | None |