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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser
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Search by   State & Plan   ZIP & Plan   PlanID   FormularyID .
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PlanType:* PDP     MAPD
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Selected Plan:Health Net Orange Option 1 (PDP) (S5678-034-0)
Browse Formulary by
First Letter of Drug Name:		   A  B  C  D  E  F  G  H  I  J  K  L  M
  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  0-9 
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: :Example: AARP MedicareRx Preferred (PDP) Formulary in Florida
 
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2012 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (PDP) (S5678-034-0)          
The Health Net Orange Option 1 (PDP) (S5678-034-0) Formulary for Drugs Starting with the Letter N
in CMS PDP Region 14 which includes: OH
Plan Monthly Premium: $39.10 Deductible: $320 Qualifies for LIS: No
Drugs Start 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 500MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NABUMETONE 750MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NADOLOL 20MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NADOLOL TABLETS   1 Preferred Generic Drugs $4.00 $8.00 None
NADOLOL TABLETS   1 Preferred Generic Drugs $4.00 $8.00 None
Nafcillin 10g/100mL   4 Injectable Drugs 25% 25% None
NAFCILLIN 1GM/50ML INJ   4 Injectable Drugs 25% 25% None
NAFCILLIN FOR INJECTION 1 GM/ML   4 Injectable Drugs 25% 25% None
NAFTIN 1% CREAM   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NAFTIN HCL GEL 1% 60GM TUBE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NAGLAZYME 5MG/5ML VIAL   5 Specialty Tier Drugs 25% 25% None
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   4 Injectable Drugs 25% 25% None
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   4 Injectable Drugs 25% 25% None
NALFON 200MG CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NALOXONE 1MG/ML SYRINGE   4 Injectable Drugs 25% 25% None
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG   4 Injectable Drugs 25% 25% None
NALTREXONE HCL 50MG TABLET 100 BLPK   1 Preferred Generic Drugs $4.00 $8.00 None
NAMENDA 10MG TABLET   2 Preferred Brand Drugs $45.00 $90.00 None
NAMENDA 10MG/5ML SOLUTION   2 Preferred Brand Drugs $45.00 $90.00 None
NAMENDA 5-10MG TITRATION PK   2 Preferred Brand Drugs $45.00 $90.00 None
NAMENDA 5MG TABLET   2 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NAPRELAN 375MG TABLET SA   2 Preferred Brand Drugs $45.00 $90.00 None
NAPRELAN CR 500MG TABLET 75 BOT   2 Preferred Brand Drugs $45.00 $90.00 None
NAPROXEN 125MG/5ML SUSPEN   1 Preferred Generic Drugs $4.00 $8.00 None
NAPROXEN 250 MG ORAL TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NAPROXEN 375MG TABLET EC   1 Preferred Generic Drugs $4.00 $8.00 None
NAPROXEN 500MG TABLET EC   1 Preferred Generic Drugs $4.00 $8.00 None
Naproxen 500mg/1 500 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $4.00 $8.00 None
NAPROXEN SODIUM 275 MG ORAL TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
Naproxen Sodium 550mg/1   1 Preferred Generic Drugs $4.00 $8.00 None
NAPROXEN TABLET 375MG (500 CT)   1 Preferred Generic Drugs $4.00 $8.00 None
NARATRIPTAN TABLETS   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NARATRIPTAN TABLETS   1 Preferred Generic Drugs $4.00 $8.00 None
NARDIL 15MG TABLET   2 Preferred Brand Drugs $45.00 $90.00 None
NASACORT AQ AER 55MCG/AC   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP   2 Preferred Brand Drugs $45.00 $90.00 None
NATACYN EYE DROPS   2 Preferred Brand Drugs $45.00 $90.00 None
Nateglinide 120mg/1 90 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $4.00 $8.00 None
Nateglinide 60mg/1 90 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $4.00 $8.00 None
NAVANE 10MG CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NAVANE 2MG CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NEBUPENT 300MG INHAL POWDER   2 Preferred Brand Drugs $45.00 $90.00 P
NECON 0.5/35-28 TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NECON 1/35-28 TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NECON 10/11-28 TABLET   2 Preferred Brand Drugs $45.00 $90.00 None
NECON 7 DAYS X 3 TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NEFAZODONE HCL 150MG TABLET (60 CT)   1 Preferred Generic Drugs $4.00 $8.00 None
NEFAZODONE HCL 250MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NEFAZODONE HCL 50MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   1 Preferred Generic Drugs $4.00 $8.00 None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   1 Preferred Generic Drugs $4.00 $8.00 None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   1 Preferred Generic Drugs $4.00 $8.00 None
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE in 1 CARTON / 1 mL in 1 AMPULE   1 Preferred Generic Drugs $4.00 $8.00 None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEOMYCIN SULFATE 500MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   1 Preferred Generic Drugs $4.00 $8.00 None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   1 Preferred Generic Drugs $4.00 $8.00 None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML   1 Preferred Generic Drugs $4.00 $8.00 None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   1 Preferred Generic Drugs $4.00 $8.00 None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   1 Preferred Generic Drugs $4.00 $8.00 None
NEORAL 100MG GELATN CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 P
NEORAL 100MG/ML SOLUTION   3 Non-Preferred Brand Drugs $80.00 $200.00 P
NEORAL 25MG GELATIN CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 P
NEPHRAMINE SOLUTION FOR INJECTION   4 Injectable Drugs 25% 25% None
NEULASTA 6MG/0.6ML SYRINGE   5 Specialty Tier Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEUPOGEN 300MCG/ML VIAL   5 Specialty Tier Drugs 25% 25% P
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE   5 Specialty Tier Drugs 25% 25% P
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR   5 Specialty Tier Drugs 25% 25% P
NEURONTIN 100MG CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NEURONTIN 250MG/5ML TUBEX   2 Preferred Brand Drugs $45.00 $90.00 None
NEURONTIN 300MG CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NEURONTIN 400MG CAPSULE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NEURONTIN 600MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NEURONTIN 800MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NEVANAC 0.1% DROPTAINER   2 Preferred Brand Drugs $45.00 $90.00 None
nevirapine 200 mg tablet   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEXAVAR TABLETS 200MG 120 BOT   5 Specialty Tier Drugs 25% 25% None
NEXIUM IV 20MG VIAL   4 Injectable Drugs 25% 25% None
NEXIUM IV 40MG VIAL   4 Injectable Drugs 25% 25% None
NEXT CHOICE 0.75 MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NIACOR 500MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NIASPAN 1000MG TABLET (90 CT)   2 Preferred Brand Drugs $45.00 $90.00 None
NIASPAN ER 500MG TABLET (90 CT)   2 Preferred Brand Drugs $45.00 $90.00 None
NIASPAN ER 750MG TABLET (90 CT)   2 Preferred Brand Drugs $45.00 $90.00 None
NICARDIPINE HYDROCHLORIDE 2.5mg/mL   4 Injectable Drugs 25% 25% None
NICARDIPINE HYDROCHLORIDE CAPSULES   1 Preferred Generic Drugs $4.00 $8.00 None
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NIFEDIAC CC 30MG TABLET SA   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDIAC CC 60MG TABLET SA   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDIAC CC 90MG TABLET SA   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR   1 Preferred Generic Drugs $4.00 $8.00 None
Nifedipine 10mg/1 100 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDIPINE 20MG CAPSULE   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDIPINE TABLETS EXTENDED RELEASE   1 Preferred Generic Drugs $4.00 $8.00 None
NIFEDIPINE TABLETS EXTENDED RELEASE   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NIFEDIPINE TABLETS EXTENDED RELEASE   1 Preferred Generic Drugs $4.00 $8.00 None
NILANDRON 150MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NIMODIPINE 30MG CAPSULE   1 Preferred Generic Drugs $4.00 $8.00 None
NIPENT FOR INJECTION 10MG VIALS   4 Injectable Drugs 25% 25% None
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $4.00 $8.00 None
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $4.00 $8.00 None
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $4.00 $8.00 None
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $4.00 $8.00 None
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET   1 Preferred Generic Drugs $4.00 $8.00 None
NITRO-DUR 0.3MG/HR PATCH   2 Preferred Brand Drugs $45.00 $90.00 None
NITRO-DUR 0.8MG/HR PATCH INST.   2 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NITROFURANTOIN MCR 50MG CAP   1 Preferred Generic Drugs $4.00 $8.00 None
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $4.00 $8.00 None
NITROGLYCERIN .2MG/HR PATCH   1 Preferred Generic Drugs $4.00 $8.00 None
NITROGLYCERIN .4MG/HR PATCH   1 Preferred Generic Drugs $4.00 $8.00 None
NITROGLYCERIN .6MG/HR PATCH   1 Preferred Generic Drugs $4.00 $8.00 None
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE   4 Injectable Drugs 25% 25% None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   1 Preferred Generic Drugs $4.00 $8.00 None
Nitrolingual Pumpspray 400ug/1 200 SPRAY, METERED in 1 BOTTLE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NITROMIST AEROSOL   2 Preferred Brand Drugs $45.00 $90.00 None
NITROSTAT 0.3MG TABLET SL   2 Preferred Brand Drugs $45.00 $90.00 None
NITROSTAT 0.4MG TABLET SL   2 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NITROSTAT 0.6MG TABLET SL   2 Preferred Brand Drugs $45.00 $90.00 None
NIZATIDINE 150MG CAPSULE   1 Preferred Generic Drugs $4.00 $8.00 None
NIZATIDINE 300 MG CAPSULE (100 CAPS)   1 Preferred Generic Drugs $4.00 $8.00 None
NIZATIDINE ORAL SOLUTION 15MG/ML   1 Preferred Generic Drugs $4.00 $8.00 None
NORA-BE 0.35MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   4 Injectable Drugs 25% 25% None
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier Drugs 25% 25% None
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   4 Injectable Drugs 25% 25% None
NORDITROPIN NORDIFLEX INJECTION   5 Specialty Tier Drugs 25% 25% None
NORETHINDRONE 5MG TABLET   1 Preferred Generic Drugs $4.00 $8.00 None
NORITATE 1% CREAM   3 Non-Preferred Brand Drugs $80.00 $200.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NORMOSOL -R INJ /D5W   4 Injectable Drugs 25% 25% None
NORMOSOL-M AND DEXTROSE 5%   4 Injectable Drugs 25% 25% None
NORMOSOL-R PH 7.4 IV SOLUTION   4 Injectable Drugs 25% 25% None
NOROXIN 400mg/1 20 TABLET, FILM COATED in 1 BOTTLE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORPACE CR 100MG CAPSULE SA   2 Preferred Brand Drugs $45.00 $90.00 None
NORPRAMIN 100MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORPRAMIN 10MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORPRAMIN 150MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORPRAMIN 25MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORPRAMIN 50MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORPRAMIN 75MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 21 TABLET in 1 BLISTER PACK   1 Preferred Generic Drugs $4.00 $8.00 None
Nortrel (28 Day Regimen) 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   1 Preferred Generic Drugs $4.00 $8.00 None
NORTREL 1-0.035MG TABLET 28DAY   1 Preferred Generic Drugs $4.00 $8.00 None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   1 Preferred Generic Drugs $4.00 $8.00 None
NORTRIPTYLINE 10MG/5ML SOL   1 Preferred Generic Drugs $4.00 $8.00 None
NORTRIPTYLINE HCL 25MG CAP   1 Preferred Generic Drugs $4.00 $8.00 None
NORTRIPTYLINE HCL 75MG CAPSULE   1 Preferred Generic Drugs $4.00 $8.00 None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs $4.00 $8.00 None
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs $4.00 $8.00 None
NORVIR 100 MG TABLET   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NORVIR 100mg/1 30 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NORVIR 80MG/ML ORAL SOLUTION   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NOVANTRONE 2MG/ML VIAL   4 Injectable Drugs 25% 25% None
NOVAREL INJ 10000UNT   4 Injectable Drugs 25% 25% None
Novolin 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
Novolin 100[USP'U]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
Novolin R 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NOVOLOG 100U/ML VIAL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NOVOLOG FLEXPEN SYRINGE   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NOVOLOG MIX 70/30 VIAL   3 Non-Preferred Brand Drugs $80.00 $200.00 None
NOXAFIL 200MG/5ML SUSPENSION ORAL   5 Specialty Tier Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NUCYNTA 100mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET, FILM COATED in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA 50mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET, FILM COATED in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA 75mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET, FILM COATED in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED   2 Preferred Brand Drugs $45.00 $90.00 None
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED   2 Preferred Brand Drugs $45.00 $90.00 None
NUEDEXTA 20; 10mg/1; mg/1   2 Preferred Brand Drugs $45.00 $90.00 None
NULOJIX 250mg/1 1 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in   5 Specialty Tier Drugs 25% 25% P
NUTROPIN 10 MG VIAL   5 Specialty Tier Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN   5 Specialty Tier Drugs 25% 25% None
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML   5 Specialty Tier Drugs 25% 25% None
NUVARING 0.12-0.015 RING VAGINAL   2 Preferred Brand Drugs $45.00 $90.00 None
NUVIGIL 150 MG ORAL TABLET   2 Preferred Brand Drugs $45.00 $90.00 P
NUVIGIL 250 MG ORAL TABLET   2 Preferred Brand Drugs $45.00 $90.00 P
NUVIGIL 50 MG ORAL TABLET   2 Preferred Brand Drugs $45.00 $90.00 P
NYAMYC 100000 U/G POWDER   1 Preferred Generic Drugs $4.00 $8.00 None
Nystatin 100000[USP'U]/g   1 Preferred Generic Drugs $4.00 $8.00 None
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Preferred Generic Drugs $4.00 $8.00 None
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Preferred Generic Drugs $4.00 $8.00 None
Nystatin 100000[USP'U]/mL   1 Preferred Generic Drugs $4.00 $8.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NYSTATIN TABLET 500000U (100 CT)   1 Preferred Generic Drugs $4.00 $8.00 None
NYSTATIN/TRIAMCINOLONE CRM   1 Preferred Generic Drugs $4.00 $8.00 None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG   1 Preferred Generic Drugs $4.00 $8.00 None
NYSTOP 100000U/GM POWDER   1 Preferred Generic Drugs $4.00 $8.00 None



What does all this mean? Here are a few notes to help you understand the above 2012 Medicare Part D Health Net Orange Option 1 (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug 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).
  • 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 the standard $320 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 wit 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 which tier the drug is in. 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 2012 )

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 Part D plan provider.



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