MedicarePartD.guide

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2026 HealthSpring Assurance Rx (PDP) formulary (drug list)

Contract S5617, plan 219 · Georgia · 3,188 drugs on file · formulary ID 00026089. Each drug links to its cost in every CMS PDP Region 10 plan.

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132 drugs starting with R.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
RABAVERT KitRabies Vaccine3Preferred Brand21%21%
  • PA
  • QL 5 per 365 days
RALDESY TM 10 mg/mL SolutionTrazodone Hydrochloride Oral5Specialty Tier25%N/ANone
RALOXIFENE HYDROCHLORIDE 60 mg Tablet, Film Coated3Preferred Brand21%21%
  • QL 3 per 30 days
RAMIPRIL 1.25 mg Capsule1Preferred Generic$0.00$0.00None
RAMIPRIL 10 mg Capsule1Preferred Generic$0.00$0.00None
RAMIPRIL 2.5 mg Capsule1Preferred Generic$0.00$0.00None
RAMIPRIL 5 mg Capsule1Preferred Generic$0.00$0.00None
RANOLAZINE 1000 mg Tablet, Extended Release4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RANOLAZINE 500 mg Tablet, Extended Release4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RASAGILINE .5 mg Tablet4Non-Preferred Drug31%31%None
RASAGILINE 1 mg Tablet4Non-Preferred Drug31%31%None
RECLIPSEN 28 DAY KitDesogestrel And Ethinyl Estradiol4Non-Preferred Drug31%31%None
RECOMBIVAX HB 10 ug/mL Injection, SuspensionHepatitis B Vaccine (Recombinant)3Preferred Brand21%21%
  • PA
RECOMBIVAX HB 10 ug/mL Injection, SuspensionHepatitis B Vaccine (Recombinant)3Preferred Brand21%21%
  • PA
RECOMBIVAX HB 40 ug/mL Injection, SuspensionHepatitis B Vaccine (Recombinant)3Preferred Brand21%21%
  • PA
RECOMBIVAX HB 5 ug/.5mL Injection, SuspensionHepatitis B Vaccine (Recombinant)3Preferred Brand21%21%
  • PA
REPAGLINIDE .5 mg Tablet1Preferred Generic$0.00$0.00
  • QL 96 per 30 days
REPAGLINIDE 1 mg Tablet1Preferred Generic$0.00$0.00
  • QL 48 per 30 days
REPAGLINIDE 2 mg Tablet1Preferred Generic$0.00$0.00
  • QL 24 per 30 days
REPATHA 140 mg/mL Injection, SolutionEvolocumab3Preferred Brand21%21%
  • PA
  • QL 6 per 28 days
REPATHA 140 mg/mL Injection, SolutionEvolocumab3Preferred Brand21%21%
  • PA
  • QL 6 per 28 days
RETACRIT 10000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETACRIT 10000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETACRIT 2000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETACRIT 20000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETACRIT 3000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETACRIT 4000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETACRIT 40000 [iU]/mL Injection, SolutionEpoetin Alfa-Epbx4Non-Preferred Drug31%31%
  • PA
RETEVMO 120 mg Tablet, CoatedSelpercatinib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
RETEVMO 160 mg Tablet, CoatedSelpercatinib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
RETEVMO 40 mg Tablet, CoatedSelpercatinib5Specialty Tier25%N/A
  • PA
  • QL 18 per 30 days
RETEVMO 80 mg Tablet, CoatedSelpercatinib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
REVCOVI 1.6 mg/mL InjectionElapegademase-Lvlr5Specialty Tier25%N/A
  • PA
REVUFORJ 110 mg Tablet, Film CoatedRevumenib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
REVUFORJ 160 mg Tablet, Film CoatedRevumenib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
REVUFORJ 25 mg Tablet, Film CoatedRevumenib5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
REXTOVY 4 mg/.25mL SprayNaloxone Hydrochloride3Preferred Brand21%21%None
REXULTI .25 mg TabletBrexpiprazole5Specialty Tier25%N/A
  • QL 3 per 30 days
REXULTI .5 mg TabletBrexpiprazole5Specialty Tier25%N/A
  • QL 3 per 30 days
REXULTI 1 mg TabletBrexpiprazole5Specialty Tier25%N/A
  • QL 3 per 30 days
REXULTI 2 mg TabletBrexpiprazole5Specialty Tier25%N/A
  • QL 3 per 30 days
REXULTI 3 mg TabletBrexpiprazole5Specialty Tier25%N/A
  • QL 3 per 30 days
REXULTI 4 mg TabletBrexpiprazole5Specialty Tier25%N/A
  • QL 3 per 30 days
REYATAZ 50 mg PowderAtazanavir5Specialty Tier25%N/A
  • QL 24 per 30 days
REZDIFFRA 100 mg Tablet, CoatedResmetirom5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
REZDIFFRA 60 mg Tablet, CoatedResmetirom5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
REZDIFFRA 80 mg Tablet, CoatedResmetirom5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
REZLIDHIA 150 mg CapsuleOlutasidenib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
REZUROCK 200 mg TabletBelumosudil5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
RHOPRESSA .2 mg/mL Solution/ DropsNetarsudil3Preferred Brand21%21%None
RIBAVIRIN 200 mg Capsule3Preferred Brand21%21%None
RIBAVIRIN 200 mg Tablet, Film Coated3Preferred Brand21%21%None
RIFABUTIN 150 mg Capsule4Non-Preferred Drug31%31%None
RIFAMPIN 150 mg Capsule4Non-Preferred Drug31%31%None
RIFAMPIN 300 mg Capsule4Non-Preferred Drug31%31%None
RIFAMPIN 600 mg/10mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug31%31%None
RILUZOLE 50 mg Tablet3Preferred Brand21%21%None
RIMANTADINE HYDROCHLORIDE 100 mg Tablet, Film Coated4Non-Preferred Drug31%31%None
RINVOQ 1 mg/mL SolutionUpadacitinib5Specialty Tier25%N/A
  • PA
  • QL 36 per 30 days
RINVOQ 15 mg Tablet, Extended ReleaseUpadacitinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
RINVOQ 30 mg Tablet, Extended ReleaseUpadacitinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
RINVOQ 45 mg Tablet, Extended ReleaseUpadacitinib5Specialty Tier25%N/A
  • PA
  • QL 168 per 365 days
RISPERIDONE .25 mg Tablet2Generic$2.00$2.00
  • QL 12 per 30 days
RISPERIDONE .25 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 12 per 30 days
RISPERIDONE .5 mg Tablet2Generic$2.00$2.00
  • QL 12 per 30 days
RISPERIDONE .5 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 12 per 30 days
RISPERIDONE 1 mg Tablet2Generic$2.00$2.00
  • QL 18 per 30 days
RISPERIDONE 1 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 18 per 30 days
RISPERIDONE 1 mg/mL Solution4Non-Preferred Drug31%31%None
RISPERIDONE 2 mg Tablet2Generic$2.00$2.00
  • QL 9 per 30 days
RISPERIDONE 2 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 9 per 30 days
RISPERIDONE 3 mg Tablet2Generic$2.00$2.00
  • QL 6 per 30 days
RISPERIDONE 3 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RISPERIDONE 4 mg Tablet2Generic$2.00$2.00
  • QL 12 per 30 days
RISPERIDONE 4 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 12 per 30 days
RISPERIDONE Kit4Non-Preferred Drug31%31%
  • QL 2 per 28 days
RISPERIDONE Kit5Specialty Tier25%N/A
  • QL 2 per 28 days
RISPERIDONE Kit5Specialty Tier25%N/A
  • QL 2 per 28 days
RISPERIDONE Kit4Non-Preferred Drug31%31%
  • QL 2 per 28 days
RITONAVIR 100 mg Tablet, Film Coated3Preferred Brand21%21%
  • QL 36 per 30 days
RIVAROXABAN 155 mg Granule, For Suspension3Preferred Brand21%21%None
RIVAROXABAN 2.5 mg Tablet, Film Coated3Preferred Brand21%21%None
RIVASTIGMINE 13.3 mg/24h Patch4Non-Preferred Drug31%31%None
RIVASTIGMINE 4.6 mg/24h Patch4Non-Preferred Drug31%31%None
RIVASTIGMINE 9.5 mg/24h Patch4Non-Preferred Drug31%31%None
RIVASTIGMINE TARTRATE 1.5 mg Capsule4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RIVASTIGMINE TARTRATE 3 mg Capsule4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RIVASTIGMINE TARTRATE 4.5 mg Capsule4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RIVASTIGMINE TARTRATE 6 mg Capsule4Non-Preferred Drug31%31%
  • QL 6 per 30 days
RIVELSA KitLevonorgestrel/Ethinyl Estradiol And Ethinyl Estradiol4Non-Preferred Drug31%31%None
RIZATRIPTAN BENZOATE 10 mg Tablet3Preferred Brand21%21%
  • QL 36 per 28 days
RIZATRIPTAN BENZOATE 10 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 36 per 28 days
RIZATRIPTAN BENZOATE 5 mg Tablet3Preferred Brand21%21%
  • QL 36 per 28 days
RIZATRIPTAN BENZOATE 5 mg Tablet, Orally Disintegrating4Non-Preferred Drug31%31%
  • QL 36 per 28 days
ROCKLATAN .2/.05 mg/mL Solution/ DropsNetarsudil And Latanoprost Ophthalmic Solution, 0.02%/0.005%3Preferred Brand21%21%None
ROFLUMILAST 250 ug Tablet4Non-Preferred Drug31%31%
  • PA
  • QL 3 per 30 days
ROFLUMILAST 500 ug Tablet4Non-Preferred Drug31%31%
  • PA
  • QL 3 per 30 days
ROMVIMZA 14 mg CapsuleVimseltinib5Specialty Tier25%N/A
  • PA
  • QL 8 per 28 days
ROMVIMZA 20 mg CapsuleVimseltinib5Specialty Tier25%N/A
  • PA
  • QL 8 per 28 days
ROMVIMZA 30 mg CapsuleVimseltinib5Specialty Tier25%N/A
  • PA
  • QL 8 per 28 days
ROPINIROLE 1 mg Tablet, Film Coated2Generic$2.00$2.00None
ROPINIROLE 2 mg Tablet, Film Coated2Generic$2.00$2.00None
ROPINIROLE HYDROCHLORIDE .25 mg Tablet, Film Coated2Generic$2.00$2.00None
ROPINIROLE HYDROCHLORIDE .5 mg Tablet, Film Coated2Generic$2.00$2.00None
ROPINIROLE HYDROCHLORIDE 3 mg Tablet, Film Coated2Generic$2.00$2.00None
ROPINIROLE HYDROCHLORIDE 4 mg Tablet, Film Coated2Generic$2.00$2.00None
ROPINIROLE HYDROCHLORIDE 5 mg Tablet, Film Coated2Generic$2.00$2.00None
ROSUVASTATIN 40 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ROSUVASTATIN CALCIUM 10 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ROSUVASTATIN CALCIUM 20 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ROSUVASTATIN CALCIUM 5 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ROSYRAH KitLevonorgestrel And Ethinyl Estradiol And Ethinyl Estradiol4Non-Preferred Drug31%31%None
ROTATEQ 2200000/2800000/2200000/2000000/2300000 [iU]/2mL SolutionRotavirus Vaccine, Live, Oral, Pentavalent3Preferred Brand21%21%None
ROZLYTREK 100 mg CapsuleEntrectinib5Specialty Tier25%N/A
  • PA
  • QL 15 per 30 days
ROZLYTREK 200 mg CapsuleEntrectinib5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ROZLYTREK 50 mg/201 PelletEntrectinib5Specialty Tier25%N/A
  • PA
  • QL 36 per 30 days
RUBRACA 200 mg Tablet, Film CoatedRucaparib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
RUBRACA 250 mg Tablet, Film CoatedRucaparib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
RUBRACA 300 mg Tablet, Film CoatedRucaparib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
RUFINAMIDE 200 mg Tablet, Film Coated3Preferred Brand21%21%
  • PA
RUFINAMIDE 40 mg/mL Suspension5Specialty Tier25%N/A
  • PA
RUFINAMIDE 400 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
RUKOBIA 600 mg Tablet, Film Coated, Extended ReleaseFostemsavir Tromethamine5Specialty Tier25%N/ANone
RYALTRIS 665/25 ug Spray, MeteredOlopatadine Hydrochloride And Mometasone Furoate4Non-Preferred Drug31%31%
  • ST
RYBELSUS 14 mg TabletOral Semaglutide3Preferred Brand21%21%
  • PA
  • QL 3 per 30 days
RYBELSUS 3 mg TabletOral Semaglutide3Preferred Brand21%21%
  • PA
  • QL 3 per 30 days
RYBELSUS 7 mg TabletOral Semaglutide3Preferred Brand21%21%
  • PA
  • QL 3 per 30 days
RYDAPT 25 mg Capsule, Liquid Filled5Specialty Tier25%N/A
  • PA
  • QL 224 per 28 days
RYTARY 145/36.25 mg Capsule, Extended ReleaseCarbidopa And Levodopa4Non-Preferred Drug31%31%
  • ST
RYTARY 195/48.75 mg Capsule, Extended ReleaseCarbidopa And Levodopa4Non-Preferred Drug31%31%
  • ST
RYTARY 245/61.25 mg Capsule, Extended ReleaseCarbidopa And Levodopa4Non-Preferred Drug31%31%
  • ST
RYTARY 95/23.75 mg Capsule, Extended ReleaseCarbidopa And Levodopa4Non-Preferred Drug31%31%
  • ST

PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.