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Blue Shield Rx Enhanced (PDP) (S2468-004-0)
Tier 1 (271)
Tier 2 (1137)
Tier 3 (537)
Tier 4 (799)
Tier 5 (663)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2020 Medicare Part D Plan Formulary Information
Blue Shield Rx Enhanced (PDP) (S2468-004-0)
Benefit Details           
The Blue Shield Rx Enhanced (PDP) (S2468-004-0)
Formulary Drugs Starting with the Letter N

in CMS PDP Region 32 which includes: CA
Plan Monthly Premium: $118.40 Deductible: $0 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
NABUMETONE 500 MG TABLET [Relafen]   2 Generic $7.00$14.00None
NABUMETONE 750 MG TABLET   2 Generic $7.00$14.00None
NADOLOL 20 MG TABLET   2 Generic $7.00$14.00None
NADOLOL 40 MG TABLET [Corgard]   2 Generic $7.00$14.00None
NADOLOL 80 MG TABLET   2 Generic $7.00$14.00None
NAFCILLIN 1 GM VIAL   4 Non-Preferred Drug 27%27%None
NAFCILLIN 10 GM BULK VIAL   5 Specialty Tier 33%N/ANone
NAFCILLIN 2 GM VIAL   4 Non-Preferred Drug 27%27%None
NALOXONE 0.4 MG/ML CARPUJECT CARTRIDGE [Narcan]   2 Generic $7.00$14.00Q:2
/30Days
NALOXONE 0.4 MG/ML VIAL   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
naloxone 1 mg/ml syringe   2 Generic $7.00$14.00None
NALTREXONE 50 MG TABLET   2 Generic $7.00$14.00None
NAMZARIC 14 MG-10 MG CAPSULE   4 Non-Preferred Drug 27%27%Q:1
/1Days
NAMZARIC 21 MG-10 MG CAPSULE   4 Non-Preferred Drug 27%27%Q:1
/1Days
NAMZARIC 28 MG-10 MG CAPSULE   4 Non-Preferred Drug 27%27%Q:1
/1Days
NAMZARIC 7 MG-10 MG CAPSULE   4 Non-Preferred Drug 27%27%Q:1
/1Days
NAMZARIC TITRATION PACK   4 Non-Preferred Drug 27%27%Q:28
/28Days
NAPROXEN 250 MG TABLET [Naprosyn]   2 Generic $7.00$14.00None
NAPROXEN 375 MG TABLET   2 Generic $7.00$14.00None
NAPROXEN 500 MG TABLET   2 Generic $7.00$14.00None
NAPROXEN DR 375 MG TABLET   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAPROXEN DR 500 MG TABLET DR [EC-Naprosyn]   2 Generic $7.00$14.00None
NARATRIPTAN HCL 1 MG TABLET   2 Generic $7.00$14.00Q:18
/30Days
NARATRIPTAN HCL 2.5 MG TABLET   2 Generic $7.00$14.00Q:18
/30Days
NARCAN 4 MG NASAL SPRAY   4 Non-Preferred Drug 27%27%Q:2
/30Days
NATACYN EYE DROPS   3 Preferred Brand $40.00$80.00None
NATEGLINIDE 120 MG TABLET [Starlix]   1 Preferred Generic $2.00$4.00Q:3
/1Days
NATEGLINIDE 60 MG TABLET [Starlix]   1 Preferred Generic $2.00$4.00Q:6
/1Days
NATPARA 100 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NATPARA 25 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NATPARA 50 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NATPARA 75 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAYZILAM 5 MG NASAL SPRAY   5 Specialty Tier 33%N/AQ:10
/30Days
NECON 0.5-35-28 TABLET   2 Generic $7.00$14.00None
NEFAZODONE HCL 150MG TABLET (60 CT)   3 Preferred Brand $40.00$80.00None
NEFAZODONE HCL 250MG TABLET   3 Preferred Brand $40.00$80.00None
NEFAZODONE HCL 50MG TABLET   3 Preferred Brand $40.00$80.00None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   3 Preferred Brand $40.00$80.00None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   3 Preferred Brand $40.00$80.00None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   2 Generic $7.00$14.00None
NEOMYC-POLYM-DEXAMET EYE OINTMENT [Poly-Dex]   2 Generic $7.00$14.00None
NEOMYC-POLYM-DEXAMETH EYE DROP   2 Generic $7.00$14.00None
NEOMYCIN SULFATE 500MG TABLET   2 Generic $7.00$14.00None
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 $7.00$14.00None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   4 Non-Preferred Drug 27%27%None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   2 Generic $7.00$14.00None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   2 Generic $7.00$14.00None
NERLYNX 40 MG TABLET   5 Specialty Tier 33%N/AP Q:6
/1Days
NEULASTA 6MG/0.6ML SYRINGE   5 Specialty Tier 33%N/AP
NEUPRO 1 MG/24 HR PATCH   4 Non-Preferred Drug 27%27%Q:30
/30Days
NEUPRO 2 MG/24 HR PATCH   4 Non-Preferred Drug 27%27%Q:30
/30Days
NEUPRO 3 MG/24 HR PATCH   4 Non-Preferred Drug 27%27%Q:30
/30Days
NEUPRO 4 MG/24 HR PATCH   4 Non-Preferred Drug 27%27%Q:30
/30Days
NEUPRO 6 MG/24 HR PATCH   4 Non-Preferred Drug 27%27%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEUPRO 8 MG/24 HR PATCH   4 Non-Preferred Drug 27%27%Q:30
/30Days
NEVIRAPINE 200 MG TABLET   2 Generic $7.00$14.00Q:2
/1Days
NEVIRAPINE 50 MG/5 ML SUSP Oral Suspension [Viramune]   4 Non-Preferred Drug 27%27%Q:40
/1Days
NEVIRAPINE ER 100 MG TABLET ER 24H [Viramune XR]   4 Non-Preferred Drug 27%27%Q:3
/1Days
NEVIRAPINE ER 400 MG TABLET   4 Non-Preferred Drug 27%27%Q:1
/1Days
NEXAVAR TABLETS 200MG 120 BOT   5 Specialty Tier 33%N/AP Q:4
/1Days
NIACIN ER 1,000 MG TABLET [Niaspan ER]   3 Preferred Brand $40.00$80.00Q:2
/1Days
NIACIN ER 500 MG TABLET [Niaspan ER]   3 Preferred Brand $40.00$80.00Q:4
/1Days
NIACIN ER 750 MG TABLET [Niaspan ER]   3 Preferred Brand $40.00$80.00Q:2
/1Days
NIACOR 500 MG TABLET   2 Generic $7.00$14.00None
Nicardipine hydrochloride 20 MG Oral Capsule   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Nicardipine hydrochloride 30 MG Oral Capsule   2 Generic $7.00$14.00None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   4 Non-Preferred Drug 27%27%None
NIFEDIPINE 10 MG CAPSULE [Procardia]   2 Generic $7.00$14.00None
NIFEDIPINE 20MG CAPSULE   2 Generic $7.00$14.00None
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL]   2 Generic $7.00$14.00None
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL]   2 Generic $7.00$14.00None
NIFEDIPINE ER 60 MG TABLET   2 Generic $7.00$14.00None
NIFEDIPINE ER 60 MG TABLET ER [Procardia XL]   2 Generic $7.00$14.00None
NIFEDIPINE ER 90 MG TABLET ER [Nifediac CC]   2 Generic $7.00$14.00None
NIFEDIPINE ER 90 MG TABLET ER [Procardia XL]   2 Generic $7.00$14.00None
NIKKI 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NILUTAMIDE 150 MG TABLET [Nilandron]   5 Specialty Tier 33%N/AQ:1
/1Days
NIMODIPINE 30 MG CAPSULE   4 Non-Preferred Drug 27%27%None
NINLARO 2.3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/21Days
NINLARO 3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/21Days
NINLARO 4 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/21Days
NITISINONE 10 MG CAPSULE [Orfadin]   5 Specialty Tier 33%N/AP Q:14
/1Days
NITISINONE 2 MG CAPSULE [Orfadin]   5 Specialty Tier 33%N/AP Q:70
/1Days
NITISINONE 5 MG CAPSULE [Orfadin]   5 Specialty Tier 33%N/AP Q:20
/1Days
NITRO-BID 2% OINTMENT   3 Preferred Brand $40.00$80.00None
Nitrofurantoin 25mg/5mL   3 Preferred Brand $40.00$80.00None
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin]   2 Generic $7.00$14.00None
NITROFURANTOIN MCR 25 MG CAP   2 Generic $7.00$14.00None
NITROFURANTOIN MONO-MCR 100 MG CAPSULE [Macrobid]   2 Generic $7.00$14.00None
NITROGLYCERIN 0.2 MG/HR PATCH   2 Generic $7.00$14.00None
NITROGLYCERIN 0.3 MG TABLET SL   3 Preferred Brand $40.00$80.00None
NITROGLYCERIN 0.4 MG SUSLIGUAL TABLET [Nitrotab]   3 Preferred Brand $40.00$80.00None
NITROGLYCERIN 0.4 MG/HR PATCH   2 Generic $7.00$14.00None
NITROGLYCERIN 0.6 MG SUSLIGUAL TABLET [Nitrotab]   3 Preferred Brand $40.00$80.00None
NITROGLYCERIN 0.6 MG/HR PATCH   2 Generic $7.00$14.00None
NITROGLYCERIN LINGUAL 0.4 MG   4 Non-Preferred Drug 27%27%None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROSTAT 0.3MG TABLET SL   3 Preferred Brand $40.00$80.00None
NITROSTAT 0.4 MG TABLET SL [Nitrotab]   3 Preferred Brand $40.00$80.00None
NITROSTAT 0.6MG TABLET SL   3 Preferred Brand $40.00$80.00None
NITYR 10 MG TABLET   5 Specialty Tier 33%N/AP
NITYR 2 MG TABLET   5 Specialty Tier 33%N/AP
NITYR 5 MG TABLET   5 Specialty Tier 33%N/AP
NIZATIDINE 15 MG/ML SOLUTION   2 Generic $7.00$14.00None
NIZATIDINE 150 MG CAPSULE [Axid]   2 Generic $7.00$14.00None
NIZATIDINE 300 MG CAPSULE [Axid]   2 Generic $7.00$14.00None
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier 33%N/AP
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier 33%N/AP
NORDITROPIN FLEXPRO 30 MG/3 ML   5 Specialty Tier 33%N/AP
noret-estr-fe 0.4-0.035(21)-75   2 Generic $7.00$14.00None
NORETHIN-ETH ESTRAD 1 MG-5 MCG   4 Non-Preferred Drug 27%27%P
NORETHIND-ETH ESTRAD 1-0.02 MG   2 Generic $7.00$14.00None
NORETHINDRONE 0.35 MG TABLET [Sharobel 28-Day]   2 Generic $7.00$14.00None
NORETHINDRONE 5MG TABLET   2 Generic $7.00$14.00None
NORG-EE 0.18-0.215-0.25/0.035   2 Generic $7.00$14.00None
NORG-ETHIN ESTRA 0.25-0.035 MG   2 Generic $7.00$14.00None
NORMOSOL-M AND DEXTROSE 5%   4 Non-Preferred Drug 27%27%None
NORTHERA 100 MG CAPSULE   5 Specialty Tier 33%N/AP Q:252
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORTHERA 200 MG CAPSULE   5 Specialty Tier 33%N/AP Q:126
/90Days
NORTHERA 300 MG CAPSULE   5 Specialty Tier 33%N/AP Q:84
/90Days
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK   2 Generic $7.00$14.00None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $7.00$14.00None
NORTREL 1-0.035MG TABLET 28DAY   2 Generic $7.00$14.00None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   2 Generic $7.00$14.00None
NORTRIPTYLINE 10 MG/5 ML SOL   2 Generic $7.00$14.00None
NORTRIPTYLINE HCL 25MG CAP   2 Generic $7.00$14.00None
NORTRIPTYLINE HCL 50 MG CAP   2 Generic $7.00$14.00None
NORTRIPTYLINE HCL 75 MG CAP   2 Generic $7.00$14.00None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORVIR 100 MG POWDER PACKET   4 Non-Preferred Drug 27%27%Q:12
/1Days
NORVIR 80MG/ML ORAL SOLUTION   4 Non-Preferred Drug 27%27%Q:15
/1Days
NOXAFIL 200MG/5ML SUSPENSION ORAL   5 Specialty Tier 33%N/AP
NUBEQA 300 MG TABLET   5 Specialty Tier 33%N/AP Q:4
/1Days
NUCALA 100 MG VIAL   5 Specialty Tier 33%N/AP Q:3
/28Days
NUCALA 100 MG/ML AUTO-INJECTOR AUTO INJCT   5 Specialty Tier 33%N/AP Q:3
/28Days
NUCALA 100 MG/ML SYRINGE   5 Specialty Tier 33%N/AP Q:3
/28Days
NUPLAZID 10 MG TABLET   5 Specialty Tier 33%N/AP Q:1
/1Days
NUPLAZID 34 MG CAPSULE   5 Specialty Tier 33%N/AP Q:1
/1Days
NUTRILIPID 20 % EMULSION   4 Non-Preferred Drug 27%27%P
NYAMYC 100,000 UNITS/GM POWDER   2 Generic $7.00$14.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NYMALIZE 60 MG/10 ML ORAL SYRINGE   5 Specialty Tier 33%N/AQ:1260
/21Days
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF]   2 Generic $7.00$14.00None
NYSTATIN 100,000 UNIT/GM OINTMENT [Nystex]   2 Generic $7.00$14.00None
NYSTATIN 100,000 UNIT/GM POWDER [Pedi-Dri]   2 Generic $7.00$14.00None
Nystatin 100000[USP'U]/mL   2 Generic $7.00$14.00None
NYSTATIN 500,000 UNIT ORAL TAB   2 Generic $7.00$14.00None
NYSTATIN-TRIAMCINOLONE OINTMENT [Mytrex]   4 Non-Preferred Drug 27%27%None
NYSTATIN/TRIAMCINOLONE CRM   4 Non-Preferred Drug 27%27%None
NYSTOP 100,000 UNITS/GM POWDER   2 Generic $7.00$14.00None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Blue Shield Rx Enhanced (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $435 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).

  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.


(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2020 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.