2015 MedicareBlue Rx Standard (PDP) Drug Coverage Details



Below is the Formulary, or drug list, for MedicareBlue Rx Standard (PDP) from Wellmark Ia & Sd, & Bcbs Mn, Mt, Ne, Nd,& Wy This formulary is a list of prescription medications that are covered under Wellmark Ia & Sd, & Bcbs Mn, Mt, Ne, Nd,& Wy's 2015 Part-D Plan. The MedicareBlue Rx Standard (PDP) plan has a $320 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $2960. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $2960 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2015 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. MedicareBlue Rx Standard (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.





Plan Name:
MedicareBlue Rx Standard (PDP)
Plan ID:
S5743-001
Provider: Wellmark Ia & Sd, & Bcbs Mn, Mt, Ne, Nd,& Wy
Plan Year:2015
Premium:$51.20
Deductible:$320
Initial Coverage Limit:$2960
Coverage Area:Upper Midwest and Northern Plains (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming)






Current Table info:


Coverage level : Initial Coverage
Days Supply : 30 Days
Drugs Starting With Letter: N



Change Table Options:


Drugs Starting Letter:
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 

Coverage Level:
Pre-deductible,Initial Coverage
Coverage Gap, Catastrophic

Drug Days Pricing:
30 Day Supply, 60 Day Supply, 90 Day Supply

(Mouse over for Tips)
(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization Y/N Step Therapy Y/N Does the Deduct Apply Cost Prefered Max Cost Pref Cost Non Pref Max Cost Non Pref Cost Amt Mail Max Cost Mail
Nabumetone 500mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N N Y $6None$6None$6None
Nabumetone 750mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $6None$6None$6None
Nafcillin 1g/4mL 10 Vial In 1 Carton > 4 Ml In 1 Vial
4
N N N N Y $95None$95None$95None
Nafcillin 10g/100mL 1 Vial, Pharmacy Bulk Package In 1 Carton > 100 Ml In 1 Vial, Pharmacy Bulk Package
5
N N N N Y 25%None25%None25%None
Naglazyme 5mg/5mL 1 Vial In 1 Carton > 5 Ml In 1 Vial
5
N N Y N Y 25%None25%None25%None
Naloxone Hydrochloride 1mg/mL 10 Syringe In 1 Box > 2 Ml In 1 Syringe
3
N N N N Y $22None$22None$22None
Naltrexone Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
3
N N N N Y $22None$22None$22None
Namenda 2mg/mL 360 Ml In 1 Bottle
3
N N Y N Y $22None$22None$22None
Namenda 1 Kit In 1 Blister Pack
4
N N Y N Y $95None$95None$95None
Namenda 7mg 30 Capsule, Extended Release In 1 Bottle
4
30 30 Y N Y $95None$95None$95None
Namenda 14mg 90 Capsule, Extended Release In 1 Bottle
4
30 30 Y N Y $95None$95None$95None
Namenda 21mg 30 Capsule, Extended Release In 1 Bottle
4
N N Y N Y $95None$95None$95None
Namenda 28mg 90 Capsule, Extended Release In 1 Bottle
4
N N Y N Y $95None$95None$95None
Naphazoline 1mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
1
N N N N Y $0None$0None$0None
Naproxen 375mg 500 Tablet In 1 Bottle
1
N N N N Y $0None$0None$0None
Naproxen 500mg 500 Tablet In 1 Bottle
1
N N N N Y $0None$0None$0None
Naproxen 375mg 100 Tablet, Delayed Release In 1 Bottle
2
N N N N Y $6None$6None$6None
Naproxen 500mg 100 Tablet, Delayed Release In 1 Bottle
2
N N N N Y $6None$6None$6None
Naproxen 125mg/5mL 500 Ml In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Naproxen 250mg 100 Tablet In 1 Bottle
1
N N N N Y $0None$0None$0None
Naproxen Sodium 275mg 500 Tablet In 1 Bottle
2
N N N N Y $6None$6None$6None
Naproxen Sodium 550mg 500 Tablet In 1 Bottle
2
N N N N Y $6None$6None$6None
Nasonex 50ug 1 Bottle, Pump In 1 Carton > 120 Spray, Metered In 1 Bottle, Pump
4
34 30 N N Y $95None$95None$95None
Natacyn 50mg/mL 15 Ml In 1 Bottle, Glass
4
N N N N Y $95None$95None$95None
Nateglinide 60mg 90 Tablet In 1 Bottle
1
90 30 N N Y $0None$0None$0None
Nateglinide 120mg 90 Tablet In 1 Bottle
1
90 30 N N Y $0None$0None$0None
Nebupent 300mg/6mL 1 Vial, Single-dose In 1 Carton > 6 Ml In 1 Vial, Single-dose
4
N N Y N Y $95None$95None$95None
Necon 1/35 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
N N N N Y $22None$22None$22None
Nefazodone Hydrochloride 100mg 60 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nefazodone Hydrochloride 200mg 60 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nefazodone Hydrochloride 250mg 60 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nefazodone Hydrochloride 150mg 60 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nefazodone Hydrochloride 50mg 100 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Neomycin And Polymyxin B Sulfates And Bacitracin Z 400; 3.5; 10000[USP'U]/g; mg/g; [USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
3
N N N N Y $22None$22None$22None
Neomycin And Polymyxin B Sulfates And Dexamethason 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
2
N N N N Y $6None$6None$6None
Neomycin And Polymyxin B Sulfates And Gramicidin .025; 1.75; 10000mg/mL; mg/mL; [USP'U]/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
3
N N N N Y $22None$22None$22None
Neomycin And Polymyxin B Sulfates And Hydrocortiso 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
2
N N N N Y $6None$6None$6None
Neomycin And Polymyxin B Sulfates And Hydrocortiso 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
2
N N N N Y $6None$6None$6None
Neomycin And Polymyxin B Sulfates, Bacitracin Zinc 400; 10; 3.5; 10000[USP'U]/g; mg/g; mg/g; [USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
3
N N N N Y $22None$22None$22None
Neomycin Polymyxin B Sulfates And Dexamethasone 1; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N N Y $6None$6None$6None
Neomycin Sulfate 500mg 100 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Neoral 25mg 30 Blister Pack In 1 Carton
3
N N Y N Y $22None$22None$22None
Neoral 100mg 30 Blister Pack In 1 Carton
3
N N Y N Y $22None$22None$22None
Neoral 100mg/mL 1 Bottle In 1 Carton > 50 Ml In 1 Bottle
3
N N Y N Y $22None$22None$22None
Nephramine .014; .25; .56; .88; .64; .88; .88; .4; .2; .64g/100mL; g/100mL; g/100mL; g/100mL; g/100mL; g/100 12 Carton In 1 Case > 1 Container In 1 Carton > 250 Ml In 1 Container
4
N N Y N Y $95None$95None$95None
Neumega 10 Carton In 1 Tray
5
N N N N Y 25%None25%None25%None
Neupogen 480ug/.8mL 10 Syringe In 1 Box
5
N N Y N Y 25%None25%None25%None
Neupogen 480ug/1.6mL 10 Vial In 1 Box
5
N N Y N Y 25%None25%None25%None
Neupogen 300ug/.5mL 10 Syringe In 1 Box
5
N N Y N Y 25%None25%None25%None
Neupro 1mg/24h 30 Pouch In 1 Carton > 1 Patch In 1 Pouch > 24 H In 1 Patch
4
N N N N Y $95None$95None$95None
Neupro 2mg/24h 30 Pouch In 1 Carton > 1 Patch In 1 Pouch > 24 H In 1 Patch
4
N N N N Y $95None$95None$95None
Neupro 3mg/24h 30 Pouch In 1 Carton > 1 Patch In 1 Pouch > 24 H In 1 Patch
4
N N N N Y $95None$95None$95None
Neupro 4mg/24h 30 Pouch In 1 Carton > 1 Patch In 1 Pouch > 24 H In 1 Patch
4
N N N N Y $95None$95None$95None
Neupro 6mg/24h 30 Pouch In 1 Carton > 1 Patch In 1 Pouch > 24 H In 1 Patch
4
N N N N Y $95None$95None$95None
Neupro 8mg/24h 30 Pouch In 1 Carton > 1 Patch In 1 Pouch > 24 H In 1 Patch
4
N N N N Y $95None$95None$95None
Nevanac 1mg/mL 3 Ml In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Nevirapine 50mg/5mL 1 Bottle, Plastic In 1 Carton > 240 Ml In 1 Bottle, Plastic
4
N N N N Y $95None$95None$95None
Nevirapine 200mg 60 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nevirapine 400mg 30 Tablet, Extended Release In 1 Bottle
4
N N N N Y $95None$95None$95None
Nexavar 200mg 120 Tablet, Film Coated In 1 Bottle, Plastic
5
N N Y N Y 25%None25%None25%None
Nexium 10mg 30 Granule, Delayed Release In 1 Carton
4
30 30 N N Y $95None$95None$95None
Nexium 20mg 30 Granule, Delayed Release In 1 Carton
4
30 30 N N Y $95None$95None$95None
Nexium 2.5mg 30 Granule, Delayed Release In 1 Carton
4
N N N N Y $95None$95None$95None
Nexium 40mg 30 Granule, Delayed Release In 1 Carton
4
30 30 N N Y $95None$95None$95None
Nexium 5mg 30 Granule, Delayed Release In 1 Carton
4
N N N N Y $95None$95None$95None
Nexium 20mg 90 Capsule, Delayed Release In 1 Bottle
4
30 30 N N Y $95None$95None$95None
Nexium 40mg 90 Capsule, Delayed Release In 1 Bottle
4
30 30 N N Y $95None$95None$95None
Niacin 500mg 180 Tablet, Extended Release In 1 Bottle
4
90 30 N N Y $95None$95None$95None
Niacin 750mg 180 Tablet, Extended Release In 1 Bottle
4
N N N N Y $95None$95None$95None
Niacin 1000mg 180 Tablet, Extended Release In 1 Bottle
4
N N N N Y $95None$95None$95None
Niacor 500mg 100 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nicardipine Hydrochloride 20mg 90 Capsule In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Nicardipine Hydrochloride 30mg 500 Capsule In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Nicotrol 10mg/mL 4 Bottle, Spray In 1 Box > 10 Ml In 1 Bottle, Spray
4
N N N N Y $95None$95None$95None
Nilandron 150mg 1 Blister Pack In 1 Carton > 30 Tablet In 1 Blister Pack
5
N N N N Y 25%None25%None25%None
Nimodipine 30mg 100 Blister Pack In 1 Carton
4
N N N N Y $95None$95None$95None
Nitro-bid 20mg/g 48 Packet In 1 Box > 1 G In 1 Packet
3
N N N N Y $22None$22None$22None
Nitrofurantoin Macrocrystals 50mg 100 Capsule In 1 Bottle
4
N N Y N Y $95None$95None$95None
Nitrofurantoin Monohydrate/macrocrystals 25; 75mg/1; mg 100 Capsule In 1 Bottle, Plastic
4
N N Y N Y $95None$95None$95None
Nitroglycerin .1mg/h 30 Pouch In 1 Carton > 14 H In 1 Patch
3
N N N N Y $22None$22None$22None
Nitroglycerin Transdermal System .2mg/h 30 Pouch In 1 Box > 1 Patch In 1 Pouch > 24 H In 1 Patch
3
N N N N Y $22None$22None$22None
Nitroglycerin Transdermal System .4mg/h 30 Pouch In 1 Box > 1 Patch In 1 Pouch > 24 H In 1 Patch
3
N N N N Y $22None$22None$22None
Nitroglycerin Transdermal System .6mg/h 30 Pouch In 1 Box > 1 Patch In 1 Pouch > 24 H In 1 Patch
3
N N N N Y $22None$22None$22None
Nitrolingual Pumpspray 400ug 1 Bottle In 1 Carton > 200 Spray, Metered In 1 Bottle
3
N N N N Y $22None$22None$22None
Nitrostat .3mg 1 Bottle In 1 Carton > 100 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nitrostat .4mg 1 Bottle In 1 Carton > 100 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nitrostat .6mg 1 Bottle In 1 Carton > 100 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Nora Be .35mg 6 Package In 1 Carton > 28 Tablet In 1 Package
3
N N N N Y $22None$22None$22None
Norditropin 30mg/3mL 1 Syringe In 1 Carton > 3 Ml In 1 Syringe
5
N N Y N Y 25%None25%None25%None
Norditropin 5mg/1.5mL 1 Syringe, Plastic In 1 Carton > 1.5 Ml In 1 Syringe, Plastic
5
N N Y N Y 25%None25%None25%None
Norditropin 10mg/1.5mL 1 Syringe, Plastic In 1 Carton > 1.5 Ml In 1 Syringe, Plastic
5
N N Y N Y 25%None25%None25%None
Norditropin 15mg/1.5mL 1 Syringe, Plastic In 1 Carton > 1.5 Ml In 1 Syringe, Plastic
5
N N Y N Y 25%None25%None25%None
Norethindrone .35mg 3 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 28 Tablet In 1 Blister Pack
3
N N N N Y $22None$22None$22None
Norethindrone Acetate 5mg 50 Tablet In 1 Bottle
3
N N N N Y $22None$22None$22None
Normosol-m And Dextrose 5; 21; 128; 234g/100mL; mg/100mL; mg/100mL; mg/100mL 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 1000 Ml In 1 Bag
4
N N N N Y $95None$95None$95None
Normosol-r 30; 37; 222; 526; 502mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL 12 Bag In 1 Case > 1000 Ml In 1 Bag
4
N N N N Y $95None$95None$95None
Normosol-r And Dextrose 5; 30; 37; 222; 526; 502g/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; m 12 Bag In 1 Case > 1000 Ml In 1 Bag
4
N N N N Y $95None$95None$95None
Norpace 100mg 500 Capsule, Gelatin Coated In 1 Bottle
4
N N Y N Y $95None$95None$95None
Norpace 150mg 100 Capsule, Gelatin Coated In 1 Bottle
4
N N Y N Y $95None$95None$95None
Nortrel .035; 1mg/1; mg 3 Blister Pack In 1 Carton > 21 Tablet In 1 Blister Pack
3
N N N N Y $22None$22None$22None
Nortrel 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
N N N N Y $22None$22None$22None
Nortriptyline Hydrochloride 10mg 100 Capsule In 1 Bottle
1
N N N N Y $0None$0None$0None
Nortriptyline Hydrochloride 25mg 100 Capsule In 1 Bottle
1
N N N N Y $0None$0None$0None
Nortriptyline Hydrochloride 50mg 500 Capsule In 1 Bottle
1
N N N N Y $0None$0None$0None
Nortriptyline Hydrochloride 10mg/5mL 473 Ml In 1 Bottle
4
N N N N Y $95None$95None$95None
Nortriptyline Hydrochloride 75mg 100 Capsule In 1 Bottle, Plastic
1
N N N N Y $0None$0None$0None
Norvir 80mg/mL 240 Ml In 1 Bottle
3
N N N N Y $22None$22None$22None
Norvir 100mg 30 Tablet, Film Coated In 1 Bottle
3
N N N N Y $22None$22None$22None
Norvir 100mg 30 Capsule In 1 Bottle
3
N N N N Y $22None$22None$22None
Novolin 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N N N Y $22None$22None$22None
Novolin 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N N N Y $22None$22None$22None
Novolin 100[USP'U]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N N N Y $22None$22None$22None
Novolog 100[iU]/mL 5 Cartridge In 1 Carton > 3 Ml In 1 Cartridge
3
N N N N Y $22None$22None$22None
Novolog 100[iU]/mL 1 Vial, Glass In 1 Carton > 10 Ml In 1 Vial, Glass
3
N N N N Y $22None$22None$22None
Novolog Mix 70/30 100[iU]/mL 1 Vial, Glass In 1 Carton > 10 Ml In 1 Vial, Glass
3
N N N N Y $22None$22None$22None
Novolog Mix 70/30 100[iU]/mL 5 Syringe, Plastic In 1 Carton > 3 Ml In 1 Syringe, Plastic
3
N N N N Y $22None$22None$22None
Noxafil 40mg/mL 1 Bottle, Glass In 1 Carton > 105 Ml In 1 Bottle, Glass
5
N N N N Y 25%None25%None25%None
Noxafil 100mg 60 Tablet, Coated In 1 Bottle
5
N N N N Y 25%None25%None25%None
Nuedexta 20; 10mg/1; mg 60 Capsule, Gelatin Coated In 1 Bottle
3
N N Y N Y $22None$22None$22None
Nulojix 250mg 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
5
N N Y N Y 25%None25%None25%None
Nulytely With Flavor Packs 1 Kit In 1 Kit * .0002 L In 1 Packet * .0002 L In 1 Packet * .0002 L In 1 Packet * .0002 L In 1 Packet * 4 L In 1 Bottle
3
N N N N Y $22None$22None$22None
Nuvaring .015; .12mg/d; mg/d 3 Pouch In 1 Box
4
N N N N Y $95None$95None$95None
Nuvigil 50mg 30 Tablet In 1 Bottle
4
150 30 Y N Y $95None$95None$95None
Nuvigil 150mg 30 Tablet In 1 Bottle
4
60 30 Y N Y $95None$95None$95None
Nuvigil 250mg 30 Tablet In 1 Bottle
4
30 30 Y N Y $95None$95None$95None
Nyamyc 100000[USP'U]/g 30 G In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Nystatin 100000[USP'U]/g 1 Tube In 1 Carton > 30 G In 1 Tube
3
N N N N Y $22None$22None$22None
Nystatin 100000[USP'U]/g 1 Tube In 1 Carton > 30 G In 1 Tube
3
N N N N Y $22None$22None$22None
Nystatin 500000[USP'U] 100 Tablet, Film Coated In 1 Bottle
3
N N N N Y $22None$22None$22None
Nystatin 100000[USP'U]/mL 473 Ml In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Nystatin 100000[USP'U]/g 30 G In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None
Nystop 100000[USP&apos'U]/g 30 G In 1 Bottle, Plastic
3
N N N N Y $22None$22None$22None



Medicare Help's

Additional Notes:



Coverage Levels for S5743-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $320. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $2960
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4700 in 2015.
4.Catastrophic: Anything over $4700 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2015 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2014
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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