2010 Medicare Part D Plan Formulary Information |
Medicare Plus Blue Option B (PFFS) (H2319-009-5)
Benefit Details
|
The Medicare Plus Blue Option B (PFFS) (H2319-009-5) Formulary Drugs Starting with the Letter R in Statewide County, MI: CMS MA Region 11 which includes: MI
|
Drugs Starting with Letter R
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL |
5 |
Tier 5 |
25% | N/A | P |
RAMIPRIL 1.25MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RANEXA 1000MG TABLET SR 12HR |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RANEXA 500MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RANICLOR 250MG TABLET CHEWABLE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RANICLOR 375MG TABLET CHEWABLE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RANITIDINE 150MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE HCL 15MG/ML SYRUP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RANITIDINE HCL 25MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | None |
RANITIDINE HCL 300MG CAPSULE (30 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RANITIDINE TABLET 300MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
3 |
Tier 3 |
$70.00 | $175.00 | Q:62 /31Days |
RAPAFLO CAPSULES 8MG 90 BOT |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |
RAPAMUNE 1MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
3 |
Tier 3 |
$70.00 | $175.00 | P |
RAPAMUNE 2MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | P |
RAPIFLUX FLUOXETINE 20MG ORAL TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAZADYNE 12MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RAZADYNE 4MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RAZADYNE 8MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RAZADYNE ER 16MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |
RAZADYNE ER 24MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |
RAZADYNE ER 8MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |
RAZADYNE SOL 4MG/ML |
2 |
Tier 2 |
$30.00 | $75.00 | None |
REBETOL 200MG CAPSULE 84 EA |
4 |
Tier 4 |
25% | N/A | None |
REBETOL 40MG/ML SOLUTION |
4 |
Tier 4 |
25% | N/A | None |
REBIF 22MCG/0.5ML SYRINGE |
4 |
Tier 4 |
25% | N/A | None |
REBIF 44MCG/0.5ML SYRINGE |
4 |
Tier 4 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
4 |
Tier 4 |
25% | N/A | None |
RECLIPSEN 0.15-0.03 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
5 |
Tier 5 |
25% | N/A | P |
REGLAN 10MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REGLAN 5MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REGLAN 5MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | None |
REGONOL AMP 10MG 5ML |
5 |
Tier 5 |
25% | N/A | None |
REGRANEX 0.01% GEL |
4 |
Tier 4 |
25% | N/A | None |
RELENZA 5MG DISKHALER |
2 |
Tier 2 |
$30.00 | $75.00 | Q:20 /5Days |
RELION 70/30 INJ 100/ML |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RELION N INJ 100/ML |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELION R INJ 100/ML |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RELISTOR SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
RELPAX 20MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | S Q:6 /1Days |
RELPAX 40MG TABLET 6X2 BLPK |
3 |
Tier 3 |
$70.00 | $175.00 | S Q:6 /1Days |
REMERON 15MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REMERON 30MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REMERON 45MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REMERON SLTABLET 45MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REMICADE 100MG VIAL |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMODULIN 10MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | P |
REMODULIN 1MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | P |
REMODULIN 2.5MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | P |
REMODULIN 5MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | P |
RENAMIN 6.5% IV SOLUTION |
5 |
Tier 5 |
25% | N/A | P |
RENVELA 800MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
REPREXAIN 5-200 MG TABLET 100 EA |
1 |
Tier 1 |
$7.00 | $17.50 | None |
REPREXAIN TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
REPREXAIN TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
REQUIP 0.25MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP 0.5MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 1MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP 2MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP 3MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP 4MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP 5MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP XL ROPINIROLE HCL 2MG |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP XL ROPINIROLE HCL 4MG |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP XL ROPINIROLE HCL 8MG |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REQUIP XL TABLET 12 MG |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RESCRIPTOR 100MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RESCRIPTOR 200MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RESERPINE 0.1MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RESERPINE 0.25MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RETIN-A 0.01% GEL |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETIN-A 0.025% CREAM |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETIN-A 0.025% GEL |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETIN-A 0.05% CREAM |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETIN-A 0.1% CREAM |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETIN-A MICRO 0.04% GEL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RETIN-A MICRO 0.1% GEL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RETROVIR 100MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETROVIR 10MGML SYRUP |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETROVIR 300MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RETROVIR IV INFUSION VIAL |
5 |
Tier 5 |
25% | N/A | None |
REVATIO 20MG TABLET |
4 |
Tier 4 |
25% | N/A | P |
REVIA 50MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
REVLIMID 10MG CAPSULE (100 CT) |
4 |
Tier 4 |
25% | N/A | None |
REVLIMID 15MG CAPSULE 21 BOT |
4 |
Tier 4 |
25% | N/A | None |
REVLIMID 25MG CAPSULE (100 CT) |
4 |
Tier 4 |
25% | N/A | None |
REVLIMID 5MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
REYATAZ 100MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
REYATAZ 150MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REYATAZ 200MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
REYATAZ 300MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
RHEUMATREX 2.5MG TABLET DOSE PACK |
3 |
Tier 3 |
$70.00 | $175.00 | S |
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY |
3 |
Tier 3 |
$70.00 | $175.00 | S |
RIBAPAK 400-400MG TABLET DOSE PACK |
4 |
Tier 4 |
25% | N/A | None |
RIBAPAK 600-400MG TABLET DOSE PACK |
4 |
Tier 4 |
25% | N/A | None |
RIBAPAK 600-600MG TABLET DOSE PACK |
4 |
Tier 4 |
25% | N/A | None |
RIBASPHERE 200MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RIBASPHERE 400MG TABLET |
4 |
Tier 4 |
25% | N/A | None |
RIBASPHERE 600MG TABLET |
4 |
Tier 4 |
25% | N/A | None |
RIBASPHERE CAPSULES 200MG 42 BOT |
4 |
Tier 4 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBAVIRIN 200MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
RIBAVIRIN 200MG TABLET 168 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RIBAVIRIN TABLETS 400MG 56 TABS BOT |
4 |
Tier 4 |
25% | N/A | None |
RIBAVIRIN TABLETS 600MG 56 TABS BOT |
4 |
Tier 4 |
25% | N/A | None |
RIDAURA 3MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RIFADIN 150MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RIFADIN 300MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RIFADIN IV 600MG VIAL |
5 |
Tier 5 |
25% | N/A | None |
RIFAMATE CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RIFAMPIN 300MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 600MG VIAL |
5 |
Tier 5 |
25% | N/A | None |
RIFATER TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
RILUTEK 50MG TABLET |
4 |
Tier 4 |
25% | N/A | None |
RIMANTADINE 100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RINGERS INJECTION 1000ML BAG |
5 |
Tier 5 |
25% | N/A | None |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
5 |
Tier 5 |
25% | N/A | None |
RIOMET 500MG/5ML SOLUTION ORAL |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 0.25MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 0.5MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 1MG M-TAB |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 1MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL 1MG/ML SOLUTION |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 2MG M-TAB |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 2MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 3MG M-TAB |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 3MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 4MG M-TAB |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL 4MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERDAL CONSTA 25MG SYR |
5 |
Tier 5 |
25% | N/A | None |
RISPERDAL CONSTA 37.5MG SYR |
4 |
Tier 4 |
25% | N/A | None |
RISPERDAL CONSTA 50MG SYR |
4 |
Tier 4 |
25% | N/A | None |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
5 |
Tier 5 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL M TABLET 0.5MG |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLET 1 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLET 2 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLET 3 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLET 4 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RISPERIODONE TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
RITALIN 10MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN 20MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN 5MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN LA 10MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN LA 20MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN LA 30MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN LA 40MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITALIN-SR 20MG TABLET SA |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RITUXAN 10MG/ML VIAL |
4 |
Tier 4 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROBAXIN 100MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | None |
ROBAXIN 500MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROBAXIN-750 TABLET 750MG |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROBINUL 0.2MG/ML VIAL |
5 |
Tier 5 |
25% | N/A | None |
ROBINUL 1MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROBINUL FORTE 2MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROCALTROL 1MCG/ML ORAL TUBEX |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROCALTROL CAPS 0.25MCG 100 EA |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROCALTROL CAPS 0.5MCG 100 EA |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROCEPHIN 1GM VIAL |
5 |
Tier 5 |
25% | N/A | None |
ROCEPHIN 2GM/DEXTROSE 2.4% |
5 |
Tier 5 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROCEPHIN/DEX INJ 1GM |
5 |
Tier 5 |
25% | N/A | None |
ROMYCIN 5MG/G OINTMENT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HCL TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HCL TABLET 1 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HCL TABLET 4 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROPINIROLE HYDROCLORIDE TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROTATEQ VACCINE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ROWASA RECTAL SUSPENSION ENEMA 4GM/60ML 7 X 60ML BOTUD |
3 |
Tier 3 |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROXICET 5-325/5ML SOLUTION ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROXICET 5/325 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROXICET 5/500 CAPLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ROXICODONE 15MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROXICODONE 30MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
ROZEREM 8MG TABLET (100 CT) |
3 |
Tier 3 |
$70.00 | $175.00 | S Q:31 /31Days |
RYTHMOL 150MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RYTHMOL 225MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RYTHMOL 300MG TABLET |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RYTHMOL SR 225MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RYTHMOL SR 425MG CAPSULE |
3 |
Tier 3 |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES ER 325MG 60 BOT |
3 |
Tier 3 |
$70.00 | $175.00 | None |
RYZOLT EXTENDED RELEASE TABLETS 100MG 30 BOT |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |
RYZOLT EXTENDED RELEASE TABLETS 200MG 30 BOT |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |
RYZOLT EXTENDED RELEASE TABLETS 300MG 30 BOT |
3 |
Tier 3 |
$70.00 | $175.00 | Q:31 /31Days |