2020 Medicare Part D Plan Formulary Information |
MVP GoldValue with Part D (HMO-POS) (H3305-022-0)
Benefit Details
|
The MVP GoldValue with Part D (HMO-POS) (H3305-022-0) Formulary Drugs Starting with the Letter N in Madison County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $89.00 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 |
$15.00 | $30.00 | None |
NABUMETONE 750 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NADOLOL 20 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NADOLOL 40 MG TABLET [Corgard] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NADOLOL 80 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NAFCILLIN 1 GM VIAL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NAFCILLIN 10 GM BULK VIAL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NAFCILLIN 2 GM VIAL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NALOXONE 0.4 MG/ML CARPUJECT CARTRIDGE [Narcan] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NALOXONE 0.4 MG/ML VIAL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
naloxone 1 mg/ml syringe |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NALOXONE 2 MG AUTO-INJECTOR [EVZIO] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NALTREXONE 50 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NAMENDA XR TITRATION PACK |
4 |
Tier 4 |
27% | 27% | None |
NAMZARIC 14 MG-10 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
NAMZARIC 21 MG-10 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
NAMZARIC 28 MG-10 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
NAMZARIC 7 MG-10 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
NAMZARIC TITRATION PACK |
4 |
Tier 4 |
27% | 27% | None |
NAPROXEN 250 MG TABLET [Naprosyn] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NAPROXEN 375 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN 500 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NARATRIPTAN HCL 1 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | Q:18 /30Days |
NARATRIPTAN HCL 2.5 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | Q:9 /30Days |
NARCAN 4 MG NASAL SPRAY |
4 |
Tier 4 |
27% | 27% | Q:4 /30Days |
NATACYN EYE DROPS |
4 |
Tier 4 |
27% | 27% | None |
NATEGLINIDE 120 MG TABLET [Starlix] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NATEGLINIDE 60 MG TABLET [Starlix] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P |
NATPARA 25 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAYZILAM 5 MG NASAL SPRAY |
4 |
Tier 4 |
27% | 27% | None |
NEBUPENT 300MG INHAL POWDER |
4 |
Tier 4 |
27% | 27% | P |
NECON 0.5-35-28 TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEFAZODONE HCL 250MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEFAZODONE HCL 50MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEOMYC-POLYM-DEXAMET EYE OINTMENT [Poly-Dex] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEOMYC-POLYM-DEXAMETH EYE DROP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Tier 4 |
27% | 27% | P |
NERLYNX 40 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
NEUPRO 1 MG/24 HR PATCH |
4 |
Tier 4 |
27% | 27% | None |
NEUPRO 2 MG/24 HR PATCH |
4 |
Tier 4 |
27% | 27% | None |
NEUPRO 3 MG/24 HR PATCH |
4 |
Tier 4 |
27% | 27% | None |
NEUPRO 4 MG/24 HR PATCH |
4 |
Tier 4 |
27% | 27% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPRO 6 MG/24 HR PATCH |
4 |
Tier 4 |
27% | 27% | None |
NEUPRO 8 MG/24 HR PATCH |
4 |
Tier 4 |
27% | 27% | None |
NEVANAC 0.1% DROPTAINER |
4 |
Tier 4 |
27% | 27% | None |
NEVIRAPINE 200 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEVIRAPINE 50 MG/5 ML SUSP Oral Suspension [Viramune] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NEVIRAPINE ER 100 MG TABLET ER 24H [Viramune XR] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NEVIRAPINE ER 400 MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Tier 5 |
33% | N/A | P |
NIACIN ER 1,000 MG TABLET [Niaspan ER] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NIACIN ER 500 MG TABLET [Niaspan ER] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NIACIN ER 750 MG TABLET [Niaspan ER] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIACOR 500 MG TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
Nicardipine hydrochloride 20 MG Oral Capsule |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Nicardipine hydrochloride 30 MG Oral Capsule |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
4 |
Tier 4 |
27% | 27% | None |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
4 |
Tier 4 |
27% | 27% | None |
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIFEDIPINE ER 60 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIFEDIPINE ER 60 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIFEDIPINE ER 90 MG TABLET ER [Nifediac CC] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIFEDIPINE ER 90 MG TABLET ER [Procardia XL] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIKKI 3 MG-0.02 MG TABLET [Yaz] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NILUTAMIDE 150 MG TABLET [Nilandron] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NIMODIPINE 30 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
NINLARO 2.3 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
NINLARO 3 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
NINLARO 4 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
NISOLDIPINE ER 17 MG TABLET ER 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
NISOLDIPINE ER 20 MG TABLET 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
NISOLDIPINE ER 25.5 MG TABLET 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
NISOLDIPINE ER 30 MG TABLET 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
NISOLDIPINE ER 34 MG TABLET ER 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NISOLDIPINE ER 40 MG TABLET 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
NISOLDIPINE ER 8.5 MG TABLET ER 24H [Sular] |
4 |
Tier 4 |
27% | 27% | None |
NITISINONE 10 MG CAPSULE [Orfadin] |
5 |
Tier 5 |
33% | N/A | None |
NITISINONE 2 MG CAPSULE [Orfadin] |
5 |
Tier 5 |
33% | N/A | None |
NITISINONE 5 MG CAPSULE [Orfadin] |
5 |
Tier 5 |
33% | N/A | None |
NITRO-BID 2% OINTMENT |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROFURANTOIN MCR 25 MG CAP |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROFURANTOIN MONO-MCR 100 MG CAPSULE [Macrobid] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROGLYCERIN 0.2 MG/HR PATCH |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN 0.3 MG TABLET SL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROGLYCERIN 0.4 MG SUSLIGUAL TABLET [Nitrotab] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROGLYCERIN 0.4 MG/HR PATCH |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROGLYCERIN 0.6 MG SUSLIGUAL TABLET [Nitrotab] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROGLYCERIN 0.6 MG/HR PATCH |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROGLYCERIN LINGUAL 0.4 MG |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROSTAT 0.4 MG TABLET SL [Nitrotab] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NITYR 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITYR 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
NITYR 5 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
NIVESTYM 300 MCG/0.5 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
NIVESTYM 300 MCG/ML VIAL |
5 |
Tier 5 |
33% | N/A | None |
NIVESTYM 480 MCG/0.8 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
NIVESTYM 480 MCG/1.6 ML VIAL |
5 |
Tier 5 |
33% | N/A | None |
NIZATIDINE 15 MG/ML SOLUTION |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIZATIDINE 150 MG CAPSULE [Axid] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NIZATIDINE 300 MG CAPSULE [Axid] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORA-BE 0.35MG TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$15.00 | $30.00 | None |
Norethin-Estrad-Ferr 0.8-0.025 MG |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORETHIN-ETH ESTRAD 0.5-2.5 |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORETHIN-ETH ESTRAD 1 MG-5 MCG |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORETHIND-ETH ESTRAD 1-0.02 MG |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORETHINDRONE 0.35 MG TABLET [Sharobel 28-Day] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORG-EE 0.18-0.215-0.25/0.035 |
2 |
Tier 2 |
$15.00 | $30.00 | 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 |
$15.00 | $30.00 | None |
NORMOSOL -R INJ /D5W |
4 |
Tier 4 |
27% | 27% | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Tier 4 |
27% | 27% | None |
NORPACE CR 100 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
NORPACE CR 150MG CAPSULE SA |
4 |
Tier 4 |
27% | 27% | None |
NORTHERA 100 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | Q:90 /30Days |
NORTHERA 200 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | Q:180 /30Days |
NORTHERA 300 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | Q:180 /30Days |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORTREL 1-0.035MG TABLET 28DAY |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$15.00 | $30.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORTRIPTYLINE HCL 50 MG CAP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORTRIPTYLINE HCL 75 MG CAP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NORVIR 100 MG POWDER PACKET |
4 |
Tier 4 |
27% | 27% | None |
NORVIR 100 MG TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NOURIANZ 20 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
NOURIANZ 40 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
4 |
Tier 4 |
27% | 27% | S |
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
4 |
Tier 4 |
27% | 27% | S |
NOVOLIN 70-30 FLEXPEN INSULN PEN |
4 |
Tier 4 |
27% | 27% | S |
NOVOLIN N 100 UNIT/ML FLEXPEN INSULN PEN |
4 |
Tier 4 |
27% | 27% | S |
NOVOLIN R 100 UNIT/ML FLEXPEN INSULN PEN |
4 |
Tier 4 |
27% | 27% | S |
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL |
4 |
Tier 4 |
27% | 27% | S |
NOVOLOG 100 UNIT/ML CARTRIDGE |
4 |
Tier 4 |
27% | 27% | S |
NOVOLOG 100U/ML VIAL |
4 |
Tier 4 |
27% | 27% | S |
NOVOLOG FLEXPEN SYRINGE |
4 |
Tier 4 |
27% | 27% | S |
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML |
4 |
Tier 4 |
27% | 27% | S |
NOVOLOG MIX 70/30 VIAL |
4 |
Tier 4 |
27% | 27% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Tier 5 |
33% | N/A | P |
NOXAFIL DR 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
NUBEQA 300 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Tier 3 |
$45.00 | $90.00 | P |
NUPLAZID 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
NUPLAZID 34 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
NURTEC ODT 75 MG TABLET RAPDIS |
5 |
Tier 5 |
33% | N/A | P Q:15 /30Days |
NUZYRA 100 MG VIAL |
5 |
Tier 5 |
33% | N/A | None |
NUZYRA 150 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
NYAMYC 100,000 UNITS/GM POWDER |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN 100,000 UNIT/GM OINTMENT [Nystex] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NYSTATIN 100,000 UNIT/GM POWDER [Pedi-Dri] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Nystatin 100000[USP'U]/mL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NYSTATIN 500,000 UNIT ORAL TAB |
2 |
Tier 2 |
$15.00 | $30.00 | None |
NYSTATIN-TRIAMCINOLONE OINTMENT [Mytrex] |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
3 |
Tier 3 |
$45.00 | $90.00 | None |
NYSTOP 100,000 UNITS/GM POWDER |
2 |
Tier 2 |
$15.00 | $30.00 | None |