2012 Medicare Part D Plan Formulary Information |
BlueRx Option II (PDP) (S1030-001-0)
Benefit Details
|
The BlueRx Option II (PDP) (S1030-001-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 12 which includes: AL TN
|
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 |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | P |
RAMIPRIL 1.25MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RANEXA 1,000 MG TABLET |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
RANEXA 500 MG TABLET |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
RANITIDINE 150MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
Ranitidine 15mg/mL |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
Ranitidine 300mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | Q:30 /30Days |
RAPAFLO CAPSULES 8MG 90 BOT |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | Q:30 /30Days |
RAPAMUNE 1MG TABLET |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | P |
RAPAMUNE 2MG TABLET |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | P |
RAPAMUNE TABLETS |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | P |
RAZADYNE 12MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:60 /30Days |
RAZADYNE 4MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:60 /30Days |
RAZADYNE 8MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAZADYNE ER 16MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:30 /30Days |
RAZADYNE ER 24MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:30 /30Days |
RAZADYNE ER 8MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:30 /30Days |
RAZADYNE SOL 4MG/ML |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:200 /30Days |
REBETOL 40MG/ML SOLUTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RECLIPSEN 0.15-0.03 TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | P |
REGLAN 5MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RELISTOR 12 MG/0.6 ML VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | P |
REMERON 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:30 /30Days |
REMERON 30MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMERON 45MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:30 /30Days |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:30 /30Days |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:30 /30Days |
REMERON SLTABLET 45MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:30 /30Days |
REMICADE 100MG VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
REMODULIN 10MG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
REMODULIN 1MG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
REMODULIN 2.5MG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
REMODULIN 5MG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
RENVELA 800MG TABLET |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
REPREXAIN TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 0.25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REQUIP 0.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REQUIP 1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REQUIP 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REQUIP 3MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REQUIP 4MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REQUIP 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RESCRIPTOR 100mg/1 360 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RESCRIPTOR 200mg/1 180 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
RETIN A CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETIN-A 0.01% GEL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETIN-A 0.025% CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETIN-A 0.025% GEL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETIN-A 0.05% CREAM |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETROVIR 100mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETROVIR 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
REVATIO 20MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | P Q:90 /30Days |
REVLIMID 10MG CAPSULE (100 CT) |
4 |
Specialty Tier Drugs |
33% | 33% | Q:30 /30Days |
REVLIMID 15MG CAPSULE 21 BOT |
4 |
Specialty Tier Drugs |
33% | 33% | Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 25MG CAPSULE (100 CT) |
4 |
Specialty Tier Drugs |
33% | 33% | Q:21 /28Days |
REVLIMID 5MG CAPSULE |
4 |
Specialty Tier Drugs |
33% | 33% | Q:30 /30Days |
REYATAZ 100MG CAPSULE |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
REYATAZ 150MG CAPSULE |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
REYATAZ 200MG CAPSULE |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
REYATAZ 300MG CAPSULE |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
RIBASPHERE 200MG TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RIBASPHERE 400MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | None |
RIBASPHERE 600MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | None |
RIBASPHERE CAPSULES 200MG 42 BOT |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RIBASPHERE RibaPak 400mg/1 |
4 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE RibaPak 600mg/1 |
4 |
Specialty Tier Drugs |
33% | 33% | None |
RIBAVIRIN 200MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RIDAURA 3MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RIFADIN 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RIFADIN 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RIFADIN IV 600MG VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RIFAMPIN 300MG CAPSULE |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RIFAMPIN 600MG VIAL |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RILUTEK 50MG TABLET |
2 |
Preferred Brand Drugs |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIMANTADINE 100MG TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
RISPERDAL 0.25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL 0.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL 1MG M-TAB |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL 1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL 1MG/ML SOLUTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:480 /30Days |
RISPERDAL 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL 3MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL 4MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:120 /30Days |
RISPERDAL CONSTA 25MG SYR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL CONSTA 50MG SYR |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:2 /28Days |
RISPERDAL M TABLET 0.5MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL M-TAB 2mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL M-TAB 3mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERDAL M-TAB 4mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:120 /30Days |
Risperidone 1mg/1 7 BLISTER PACK in 1 CARTON / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:480 /30Days |
RISPERIDONE TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | S Q:60 /30Days |
RISPERIDONE TABLET 1 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLET 2 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RISPERIDONE TABLET 3 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RISPERIDONE TABLET 4 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:120 /30Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:120 /30Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RISPERIODONE TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RITALIN 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:90 /30Days |
RITALIN 20MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:90 /30Days |
RITALIN 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RITALIN-SR 20MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | Q:90 /30Days |
RITUXAN 10MG/ML VIAL |
4 |
Specialty Tier Drugs |
33% | 33% | P |
RIVASTIGMINE TARTRATE CAPSULES |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE CAPSULES |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE CAPSULES |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE CAPSULES |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:60 /30Days |
ROBAXIN 500 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
ROBINUL 1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
ROBINUL FORTE 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
Rocaltrol 0.25ug/1 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | P |
Rocaltrol 0.5ug/1 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | P |
ROCEPHIN FOR INJECTION |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
ROMYCIN 5MG/G OINTMENT |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HCL TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HCL TABLET 1 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HCL TABLET 4 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROPINIROLE HYDROCLORIDE TABLET |
1 |
Generic Drugs |
$4.00 | $8.00 | None |
ROTATEQ VACCINE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Roxicet 325; 5mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$4.00 | $8.00 | Q:360 /30Days |
ROXICODONE 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
ROXICODONE 30MG TABLET |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
ROXICODONE TABLETS 5 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RYTHMOL FILM COATED TABLETS 225 MG |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |
RYTHMOL TABLETS |
3 |
Non-Preferred Brand Drugs |
$65.00 | $130.00 | None |