2010 Medicare Part D Plan Formulary Information |
Triple-S FarmaMed (PDP) (S5907-001-0)
Benefit Details
|
The Triple-S FarmaMed (PDP) (S5907-001-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 38 which includes: PR
|
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 |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RAMIPRIL 1.25MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RANEXA 1000MG TABLET SR 12HR |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RANEXA 500MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RANITIDINE HCL 15MG/ML SYRUP |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RANITIDINE HCL 25MG/ML VIAL |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | P |
RANITIDINE TABLET 300MG (100 CT) |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RAPAMUNE 1MG TABLET |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | P |
RAPAMUNE 2MG TABLET |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | P |
RAZADYNE 12MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RAZADYNE 4MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RAZADYNE 8MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RAZADYNE ER 16MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RAZADYNE ER 24MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RAZADYNE ER 8MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REBETOL 200MG CAPSULE 84 EA |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REBIF 22MCG/0.5ML SYRINGE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
REBIF 44MCG/0.5ML SYRINGE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
REGLAN 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REGLAN 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REGLAN 5MG/ML VIAL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REGRANEX 0.01% GEL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P Q:15 /15Days |
RELENZA 5MG DISKHALER |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RELISTOR SOLUTION |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:8 /15Days |
RELPAX 20MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S Q:6 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELPAX 40MG TABLET 6X2 BLPK |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S Q:6 /30Days |
REMERON 15MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REMERON 30MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REMERON 45MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REMERON SLTABLET 45MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REMICADE 100MG VIAL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
RENAMIN 6.5% IV SOLUTION |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RENVELA 800MG TABLET |
2 |
Tier 2 / Nivel 2 |
$21.00 | $63.00 | P |
REQUIP 0.25MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 0.5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
REQUIP 1MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
REQUIP 2MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
REQUIP 3MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
REQUIP 4MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
REQUIP 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S |
RESCRIPTOR 100MG TABLET |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | None |
RESCRIPTOR 200MG TABLET |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:32 /15Days |
RETIN-A 0.01% GEL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:45 /15Days |
RETIN-A 0.025% CREAM |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:45 /15Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETIN-A 0.025% GEL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:45 /15Days |
RETIN-A 0.05% CREAM |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:45 /15Days |
RETIN-A 0.1% CREAM |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P Q:45 /15Days |
RETROVIR 100MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RETROVIR 10MGML SYRUP |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RETROVIR 300MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RETROVIR IV INFUSION VIAL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REVATIO 20MG TABLET |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
REVIA 50MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
REVLIMID 5MG CAPSULE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
REYATAZ 100MG CAPSULE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
REYATAZ 150MG CAPSULE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
REYATAZ 200MG CAPSULE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
REYATAZ 300MG CAPSULE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | S Q:9 /15Days |
RIBAVIRIN 200MG CAPSULE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
RIBAVIRIN 200MG TABLET 168 BOT |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RIDAURA 3MG CAPSULE |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | None |
RIFADIN 150MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFADIN 300MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RIFAMATE CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RIFAMPIN 300MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RIFATER TABLET |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | None |
RILUTEK 50MG TABLET |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
RIMANTADINE 100MG TABLET |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RINGERS INJECTION 1000ML BAG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | P |
RISPERDAL 0.25MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 0.5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 1MG M-TAB |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL 1MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 1MG/ML SOLUTION |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 2MG M-TAB |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 2MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 3MG M-TAB |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 3MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 4MG M-TAB |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL 4MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL CONSTA 25MG SYR |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
RISPERDAL CONSTA 50MG SYR |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERDAL M TABLET 0.5MG |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLET |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLET 1 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLET 2 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLET 3 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLET 4 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | 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 / Nivel 1 |
$6.00 | $18.00 | None |
RISPERIODONE TABLET |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
RITALIN 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RITALIN 20MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RITALIN 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RITALIN-SR 20MG TABLET SA |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
RITUXAN 10MG/ML VIAL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
ROBAXIN 100MG/ML VIAL |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | P |
ROBAXIN 500MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROBAXIN-750 TABLET 750MG |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROBINUL 1MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROBINUL FORTE 2MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROCALTROL 1MCG/ML ORAL TUBEX |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROCALTROL CAPS 0.25MCG 100 EA |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROCALTROL CAPS 0.5MCG 100 EA |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROCEPHIN 1GM VIAL |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
ROPINIROLE HCL TABLET |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
ROPINIROLE HCL TABLET 1 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
ROPINIROLE HCL TABLET 4 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HYDROCLORIDE TABLET |
1 |
Tier 1 / Nivel 1 |
$6.00 | $18.00 | None |
ROTATEQ VACCINE |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | P |
ROXICODONE 15MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROXICODONE 30MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
ROZEREM 8MG TABLET (100 CT) |
3 |
Tier 3 / Nivel 3 |
$30.00 | $90.00 | None |
RYTHMOL 150MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RYTHMOL 225MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |
RYTHMOL 300MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $30 or 25% |
25% | 25% | None |