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SilverScript Choice (PDP) (S5601-032-0)
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2021 Medicare Part D Plan Formulary Information
SilverScript Choice (PDP) (S5601-032-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-032-0)
Formulary Drugs Starting with the Letter N

in CMS PDP Region 16 which includes: WI
Plan Monthly Premium: $36.00 Deductible: $205 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 [Relafen]   2* Generic $5.00$15.00None
NABUMETONE 750 MG TABLET   2* Generic $5.00$15.00None
NAFCILLIN 1 GM VIAL   4 Non-Preferred Drug 42%42%None
NAFCILLIN 10 GM BULK VIAL   5 Specialty Tier 29%N/ANone
NAFCILLIN 2 GM VIAL   4 Non-Preferred Drug 42%42%None
NALOXONE 0.4 MG/ML CARPUJECT CARTRIDGE [Narcan]   2* Generic $5.00$15.00None
NALOXONE 0.4 MG/ML VIAL [Narcan]   2* Generic $5.00$15.00None
naloxone 1 mg/ml syringe   2* Generic $5.00$15.00None
NALTREXONE 50 MG TABLET [ReVia]   3 Preferred Brand $35.00$105.00None
NAMZARIC 14 MG-10 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAMZARIC 21 MG-10 MG CAPSULE   4 Non-Preferred Drug 42%42%None
NAMZARIC 28 MG-10 MG CAPSULE   4 Non-Preferred Drug 42%42%None
NAMZARIC 7 MG-10 MG CAPSULE   4 Non-Preferred Drug 42%42%None
NAMZARIC TITRATION PACK   4 Non-Preferred Drug 42%42%None
NAPROXEN 250 MG TABLET [Naprosyn]   1* Preferred Generic $0.00$0.00None
NAPROXEN 375 MG TABLET   1* Preferred Generic $0.00$0.00None
NAPROXEN 500 MG TABLET   1* Preferred Generic $0.00$0.00None
NAPROXEN DR 375 MG TABLET DR [EC-Naprosyn]   2* Generic $5.00$15.00None
NAPROXEN DR 500 MG TABLET DR [EC-Naprosyn]   2* Generic $5.00$15.00None
NARATRIPTAN HCL 1 MG TABLET   3 Preferred Brand $35.00$105.00Q:9
/30Days
NARATRIPTAN HCL 2.5 MG TABLET   3 Preferred Brand $35.00$105.00Q:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NARCAN 4 MG NASAL SPRAY   3 Preferred Brand $35.00$105.00None
NATACYN EYE DROPS   4 Non-Preferred Drug 42%42%None
NATEGLINIDE 120 MG TABLET [Starlix]   3 Preferred Brand $35.00$105.00Q:90
/30Days
NATEGLINIDE 60 MG TABLET [Starlix]   3 Preferred Brand $35.00$105.00Q:90
/30Days
NATPARA 100 MCG DOSE CARTRIDGE   5 Specialty Tier 29%N/AP
NATPARA 25 MCG DOSE CARTRIDGE   5 Specialty Tier 29%N/AP
NATPARA 50 MCG DOSE CARTRIDGE   5 Specialty Tier 29%N/AP
NATPARA 75 MCG DOSE CARTRIDGE   5 Specialty Tier 29%N/AP
NAYZILAM 5 MG NASAL SPRAY   4 Non-Preferred Drug 42%42%P Q:10
/30Days
NECON 0.5-35-28 TABLET   3 Preferred Brand $35.00$105.00None
NEFAZODONE HCL 150MG TABLET (60 CT)   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEFAZODONE HCL 250MG TABLET   4 Non-Preferred Drug 42%42%None
NEFAZODONE HCL 50MG TABLET   4 Non-Preferred Drug 42%42%None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   4 Non-Preferred Drug 42%42%None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   4 Non-Preferred Drug 42%42%None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   3 Preferred Brand $35.00$105.00None
NEOMYC-POLYM-DEXAMET EYE OINTMENT [Poly-Dex]   2* Generic $5.00$15.00None
NEOMYC-POLYM-DEXAMETH EYE DROP   2* Generic $5.00$15.00None
NEOMYCIN SULFATE 500MG TABLET   2* Generic $5.00$15.00None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   3 Preferred Brand $35.00$105.00None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   4 Non-Preferred Drug 42%42%None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEOMYCIN/POLYMY/HYDRO OTIC SUS   3 Preferred Brand $35.00$105.00None
NERLYNX 40 MG TABLET   5 Specialty Tier 29%N/AP
NEUPRO 1 MG/24 HR PATCH   4 Non-Preferred Drug 42%42%None
NEUPRO 2 MG/24 HR PATCH   4 Non-Preferred Drug 42%42%None
NEUPRO 3 MG/24 HR PATCH   4 Non-Preferred Drug 42%42%None
NEUPRO 4 MG/24 HR PATCH   4 Non-Preferred Drug 42%42%None
NEUPRO 6 MG/24 HR PATCH   4 Non-Preferred Drug 42%42%None
NEUPRO 8 MG/24 HR PATCH   4 Non-Preferred Drug 42%42%None
NEVIRAPINE 200 MG TABLET   3 Preferred Brand $35.00$105.00None
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION [Viramune]   4 Non-Preferred Drug 42%42%None
NEVIRAPINE ER 100 MG TABLET ER 24H [Viramune XR]   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEVIRAPINE ER 400 MG TABLET ER 24H [Viramune XR]   4 Non-Preferred Drug 42%42%None
NEXAVAR TABLETS 200MG 120 BOT   5 Specialty Tier 29%N/AP
NIACIN ER 1,000 MG TABLET [Niaspan ER]   3 Preferred Brand $35.00$105.00None
NIACIN ER 500 MG TABLET [Niaspan ER]   3 Preferred Brand $35.00$105.00Q:60
/30Days
NIACIN ER 750 MG TABLET [Niaspan ER]   3 Preferred Brand $35.00$105.00None
NIACOR 500 MG TABLET   4 Non-Preferred Drug 42%42%None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   4 Non-Preferred Drug 42%42%None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   4 Non-Preferred Drug 42%42%None
NIFEDIPINE ER 30 MG TABLET ER [Nifediac CC]   3 Preferred Brand $35.00$105.00None
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL]   3 Preferred Brand $35.00$105.00None
NIFEDIPINE ER 60 MG TABLET ER [Nifediac CC]   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIFEDIPINE ER 60 MG TABLET ER [Procardia XL]   3 Preferred Brand $35.00$105.00None
NIFEDIPINE ER 90 MG TABLET ER [Nifediac CC]   3 Preferred Brand $35.00$105.00None
NIFEDIPINE ER 90 MG TABLET ER [Procardia XL]   3 Preferred Brand $35.00$105.00None
NIKKI 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $35.00$105.00None
NILUTAMIDE 150 MG TABLET [Nilandron]   5 Specialty Tier 29%N/ANone
NIMODIPINE 30 MG CAPSULE [Nimotop]   4 Non-Preferred Drug 42%42%None
NINLARO 2.3 MG CAPSULE   5 Specialty Tier 29%N/AP
NINLARO 3 MG CAPSULE   5 Specialty Tier 29%N/AP
NINLARO 4 MG CAPSULE   5 Specialty Tier 29%N/AP
NITAZOXANIDE 500 MG TABLET [Alinia]   5 Specialty Tier 29%N/ANone
NITISINONE 10 MG CAPSULE [Orfadin]   5 Specialty Tier 29%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITISINONE 2 MG CAPSULE [Orfadin]   5 Specialty Tier 29%N/AP
NITISINONE 5 MG CAPSULE [Orfadin]   5 Specialty Tier 29%N/AP
NITRO-BID 2% OINTMENT   3 Preferred Brand $35.00$105.00None
NITRO-DUR 0.3 MG/HR PATCH   4 Non-Preferred Drug 42%42%None
NITRO-DUR 0.8 MG/HR PATCH   4 Non-Preferred Drug 42%42%None
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin]   3 Preferred Brand $35.00$105.00None
NITROFURANTOIN MCR 50 MG CAPSULE [Macrodantin]   3 Preferred Brand $35.00$105.00None
NITROGLYCERIN 0.2 MG/HR PATCH [Nitrodisc]   3 Preferred Brand $35.00$105.00None
NITROGLYCERIN 0.3 MG TABLET SL   3 Preferred Brand $35.00$105.00None
NITROGLYCERIN 0.4 MG SUBLIGUAL TABLET [Nitrotab]   3 Preferred Brand $35.00$105.00None
NITROGLYCERIN 0.4 MG/HR PATCH [Transdermal-NTG]   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROGLYCERIN 0.6 MG SUBLIGUAL TABLET [Nitrotab]   3 Preferred Brand $35.00$105.00None
NITROGLYCERIN 0.6 MG/HR PATCH [Transdermal-NTG]   3 Preferred Brand $35.00$105.00None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   3 Preferred Brand $35.00$105.00None
NITYR 10 MG TABLET   5 Specialty Tier 29%N/AP
NITYR 2 MG TABLET   5 Specialty Tier 29%N/AP
NITYR 5 MG TABLET   5 Specialty Tier 29%N/AP
NIZATIDINE 15 MG/ML SOLUTION   4 Non-Preferred Drug 42%42%None
NIZATIDINE 150 MG CAPSULE [Axid]   4 Non-Preferred Drug 42%42%None
NIZATIDINE 300 MG CAPSULE [Axid]   4 Non-Preferred Drug 42%42%None
NORA-BE 0.35MG TABLET   3 Preferred Brand $35.00$105.00None
NORETHIN-ETH ESTRAD 1 MG-5 MCG   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORETHIND-ETH ESTRAD 0.5-2.5 TABLET [Jevantique]   3 Preferred Brand $35.00$105.00None
NORETHIND-ETH ESTRAD 1-0.02 MG   3 Preferred Brand $35.00$105.00None
NORETHINDRONE 0.35 MG TABLET [Sharobel 28-Day]   3 Preferred Brand $35.00$105.00None
NORETHINDRONE 5MG TABLET   3 Preferred Brand $35.00$105.00None
NORG-EE 0.18-0.215-0.25/0.035   3 Preferred Brand $35.00$105.00None
NORG-ETHIN ESTRA 0.18-0.215-0.25/0.025   3 Preferred Brand $35.00$105.00None
NORG-ETHIN ESTRA 0.25-0.035 MG TABLET [VyLibra]   3 Preferred Brand $35.00$105.00None
NORPACE CR 100 MG CAPSULE   4 Non-Preferred Drug 42%42%None
NORPACE CR 150MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
NORTHERA 100 MG CAPSULE   5 Specialty Tier 29%N/AP Q:90
/30Days
NORTHERA 200 MG CAPSULE   5 Specialty Tier 29%N/AP Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORTHERA 300 MG CAPSULE   5 Specialty Tier 29%N/AP Q:180
/30Days
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK   3 Preferred Brand $35.00$105.00None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $35.00$105.00None
NORTREL 1-0.035MG TABLET 28DAY   3 Preferred Brand $35.00$105.00None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   3 Preferred Brand $35.00$105.00None
NORTRIPTYLINE 10 MG/5 ML SOL   4 Non-Preferred Drug 42%42%None
NORTRIPTYLINE HCL 25MG CAP   2* Generic $5.00$15.00None
NORTRIPTYLINE HCL 50 MG CAP   2* Generic $5.00$15.00None
NORTRIPTYLINE HCL 75 MG CAP   2* Generic $5.00$15.00None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE   2* Generic $5.00$15.00None
NORVIR 100 MG POWDER PACKET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORVIR 80MG/ML ORAL SOLUTION   4 Non-Preferred Drug 42%42%None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $35.00$105.00None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $35.00$105.00None
NOVOLIN 70-30 FLEXPEN INSULN PEN   3 Preferred Brand $35.00$105.00None
NOVOLIN N 100 UNIT/ML FLEXPEN INSULN PEN   3 Preferred Brand $35.00$105.00None
NOVOLIN R 100 UNIT/ML FLEXPEN INSULN PEN   3 Preferred Brand $35.00$105.00None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $35.00$105.00None
NOVOLOG 100 UNIT/ML CARTRIDGE   2* Generic $5.00$15.00None
NOVOLOG 100U/ML VIAL   2* Generic $5.00$15.00None
NOVOLOG FLEXPEN SYRINGE   2* Generic $5.00$15.00None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NOVOLOG MIX 70/30 VIAL   2* Generic $5.00$15.00None
NOXAFIL 200MG/5ML SUSPENSION ORAL   5 Specialty Tier 29%N/AQ:630
/30Days
NUBEQA 300 MG TABLET   5 Specialty Tier 29%N/AP
NUEDEXTA 20; 10mg/1; mg/1   4 Non-Preferred Drug 42%42%P Q:60
/30Days
NULYTELY SOLUTION RECON   3 Preferred Brand $35.00$105.00None
NUPLAZID 10 MG TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
NUPLAZID 34 MG CAPSULE   4 Non-Preferred Drug 42%42%P Q:30
/30Days
NUTRILIPID 20 % EMULSION   4 Non-Preferred Drug 42%42%P
NYAMYC 100,000 UNITS/GM POWDER   3 Preferred Brand $35.00$105.00Q:60
/30Days
NYLIA 7-7-7-28 TABLET [Pirmella]   3 Preferred Brand $35.00$105.00None
NYMALIZE 60 MG/10 ML ORAL SYRINGE   5 Specialty Tier 29%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NYMYO 0.25-0.035 MG (28) TABLET [VyLibra]   3 Preferred Brand $35.00$105.00None
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF]   3 Preferred Brand $35.00$105.00Q:30
/30Days
NYSTATIN 100,000 UNIT/GM OINTMENT [Nystex]   3 Preferred Brand $35.00$105.00Q:30
/30Days
NYSTATIN 100,000 UNIT/GM POWDER [Pedi-Dri]   3 Preferred Brand $35.00$105.00Q:60
/30Days
Nystatin 100000[USP'U]/mL   3 Preferred Brand $35.00$105.00None
NYSTATIN 500,000 UNIT ORAL TAB   3 Preferred Brand $35.00$105.00None
NYSTOP 100,000 UNITS/GM POWDER   3 Preferred Brand $35.00$105.00Q:60
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D SilverScript Choice (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 $445 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 $4,130) 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.

      * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 2021 )

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.