2011 Medicare Part D Plan Formulary Information |
Aetna Medicare Premier Plan (HMO) (H3152-048-0)
Sanctioned Plan
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The Aetna Medicare Premier Plan (HMO) (H3152-048-0) Formulary Drugs Starting with the Letter R in Monmouth County, NJ: CMS MA Region 4 which includes: NJ
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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: Non-Preferred Brand Drugs |
$95.00 | $190.00 | P |
RALOXIFENE 60 MG ORAL TABLET |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | Q:1 /1Days |
RAMIPRIL 1.25MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:2 /1Days |
RAMIPRIL 10MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:2 /1Days |
RAMIPRIL 5MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:2 /1Days |
RANEXA 1,000 MG TABLET |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S Q:2 /1Days |
RANEXA 500 MG TABLET |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S Q:3 /1Days |
RANITIDINE 150MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RANITIDINE HCL 15MG/ML SYRUP |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE HCL 25MG/ML VIAL |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
RANITIDINE HCL 300MG CAPSULE (30 CT) |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RANITIDINE TABLET 300MG (100 CT) |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | P Q:2 /1Days |
RAPAFLO CAPSULES 8MG 90 BOT |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | P Q:1 /1Days |
RAPAMUNE 1MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RAPAMUNE 2MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RAPAMUNE TABLETS |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | P Q:2 /1Days |
REBETOL 40MG/ML SOLUTION |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
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: Specialty Tier Drugs |
33% | 33% | P Q:12 /28Days |
REBIF 44MCG/0.5ML SYRINGE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:6 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:4 /28Days |
RECLIPSEN 0.15-0.03 TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | P |
REGRANEX 0.01% GEL |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:15 /30Days |
RELENZA 5MG DISKHALER |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:560 /365Days |
REMICADE 100MG VIAL |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RENAMIN 6.5% IV SOLUTION |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | P |
RENVELA 800MG TABLET |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | None |
REPREXAIN 5-200 MG TABLET 100 EA |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:5 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REPREXAIN TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:5 /1Days |
REPREXAIN TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:5 /1Days |
RESCRIPTOR 100MG TABLET |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | None |
RESCRIPTOR 200MG TABLET |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | None |
RESERPINE 0.1MG TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RESERPINE 0.25MG TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | None |
RETAPAMULIN 0.01 MG/MG TOPICAL OINTMENT [ALTABAX] |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
RETROVIR IV INFUSION VIAL |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
REVATIO 10 MG/12.5 ML VIAL |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:75 /1Days |
REVATIO 20MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:3 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVIA 50MG TABLET |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:1 /1Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:1 /1Days |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:1 /1Days |
REVLIMID 5MG CAPSULE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:1 /1Days |
REYATAZ 100MG CAPSULE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | None |
REYATAZ 150MG CAPSULE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | None |
REYATAZ 200MG CAPSULE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | None |
REYATAZ 300MG CAPSULE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | None |
RIBAPAK 400-400MG TABLET DOSE PACK |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIBAPAK 600-400MG TABLET DOSE PACK |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBAPAK 600-600MG TABLET DOSE PACK |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIBASPHERE 200MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:7 /1Days |
RIBASPHERE 400MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIBASPHERE 600MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIBASPHERE CAPSULES 200MG 42 BOT |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:7 /1Days |
RIBAVIRIN 200MG CAPSULE |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIBAVIRIN 200MG TABLET 168 BOT |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIBAVIRIN TABLETS 400MG 56 TABS BOT |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:2 /1Days |
RIBAVIRIN TABLETS 600MG 56 TABS BOT |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P Q:2 /1Days |
RIDAURA 3MG CAPSULE |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
RIFADIN 150MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMATE CAPSULE |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RIFAMPIN 300MG CAPSULE |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RIFAMPIN 600MG VIAL |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | None |
RIFATER TABLET |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
RILUTEK 50MG TABLET |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIMANTADINE 100MG TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RINGERS INJECTION 1000ML BAG |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
RISPERDAL 1MG M-TAB |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S |
RISPERDAL 2MG M-TAB |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL 3MG M-TAB |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S Q:2 /1Days |
RISPERDAL 4MG M-TAB |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S Q:4 /1Days |
RISPERDAL CONSTA 25MG SYR |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:100 /30Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | Q:75 /30Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | Q:100 /30Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:100 /30Days |
RISPERDAL M TABLET 0.5MG |
4 |
Tier 4: Non-Preferred Brand Drugs |
$95.00 | $190.00 | S Q:2 /1Days |
RISPERIDONE 1 MG DISINTEGRATING TABLET |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
RISPERIDONE TABLET |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLET 1 MG |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIDONE TABLET 2 MG |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIDONE TABLET 3 MG |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIDONE TABLET 4 MG |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:4 /1Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:4 /1Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RISPERIODONE TABLET |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:2 /1Days |
RITUXAN 10MG/ML VIAL |
5 |
Tier 5: Specialty Tier Drugs |
33% | 33% | P |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | None |
ROMYCIN 5MG/G OINTMENT |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 1 MG |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 4 MG |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
ROPINIROLE HYDROCLORIDE TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROTATEQ VACCINE |
3 |
Tier 3: Preferred Brand Drugs |
$45.00 | $90.00 | None |
ROXICET 5-325/5ML SOLUTION ORAL |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:60 /1Days |
ROXICET 5/325 TABLET |
1 |
Tier 1: Preferred Generic Drugs |
$5.00 | $10.00 | Q:12 /1Days |
ROXICET 5/500 CAPLET |
2 |
Tier 2: Non-Preferred Generic Drugs |
$35.00 | $70.00 | Q:8 /1Days |