2013 Medicare Part D Plan Formulary Information |
Peoples Health Secure Health (HMO SNP) (H1961-003-0)
Benefit Details
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The Peoples Health Secure Health (HMO SNP) (H1961-003-0) Formulary Drugs Starting with the Letter R in WEST BATON ROUGE Parish, LA: CMS MA Region 16 which includes: LA
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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 |
Non-Preferred Brand |
25% | 25% | None |
RAMIPRIL 1.25MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
RAMIPRIL 10MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
RAMIPRIL 5MG CAPSULE |
1 |
Preferred Generic |
25% | 25% | None |
RANEXA ER 1,000 MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
RANEXA ER 500 MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
RANITIDINE 150MG CAPSULE |
2 |
Non-Preferred Generic |
25% | 25% | None |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
25% | 25% | None |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE HCL 25MG/ML VIAL |
2 |
Non-Preferred Generic |
25% | 25% | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
25% | 25% | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Preferred Generic |
25% | 25% | None |
RAPAMUNE 1MG TABLET |
3 |
Preferred Brand |
25% | 25% | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
3 |
Preferred Brand |
25% | 25% | P |
RAPAMUNE 2MG TABLET |
3 |
Preferred Brand |
25% | 25% | P |
RAPAMUNE TABLETS |
3 |
Preferred Brand |
25% | 25% | P |
RAZADYNE 12MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RAZADYNE 4MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RAZADYNE 8MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RAZADYNE ER 16MG CAPSULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAZADYNE ER 24MG CAPSULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RAZADYNE ER 8MG CAPSULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RAZADYNE SOL 4MG/ML |
4 |
Non-Preferred Brand |
25% | 25% | None |
REBETOL 200 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
REBETOL 40MG/ML SOLUTION |
4 |
Non-Preferred Brand |
25% | 25% | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS in 1 CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | 25% | P |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS in 1 CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | 25% | P |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
25% | 25% | P |
RECLAST INJECTION |
4 |
Non-Preferred Brand |
25% | 25% | P |
RECLIPSEN 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Brand |
25% | 25% | None |
Regonol 5mg/mL 10 AMPULE in 1 CARTON / 2 mL in 1 AMPULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
REGRANEX 0.01% GEL |
3 |
Preferred Brand |
25% | 25% | None |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Brand |
25% | 25% | None |
RELISTOR 12 MG/0.6 ML KIT |
4 |
Non-Preferred Brand |
25% | 25% | P |
RELPAX 20MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | Q:6 /30Days |
RELPAX 40MG TABLET 6X2 BLPK |
4 |
Non-Preferred Brand |
25% | 25% | Q:6 /30Days |
REMERON 15MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REMERON 30MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REMERON 45MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
4 |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
4 |
Non-Preferred Brand |
25% | 25% | None |
REMERON SLTABLET 45MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REMICADE 100MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
REMODULIN 10MG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
REMODULIN 1MG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
REMODULIN 2.5MG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
REMODULIN 5MG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
RENVELA 800MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
reprexain 10-200 mg tablet |
2 |
Non-Preferred Generic |
25% | 25% | None |
reprexain 2.5-200 mg tablet |
2 |
Non-Preferred Generic |
25% | 25% | None |
reprexain 5-200 mg tablet |
2 |
Non-Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 0.25MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REQUIP 0.5MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REQUIP 1MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REQUIP 2MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REQUIP 3MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REQUIP 4MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
REQUIP 5MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
3 |
Preferred Brand |
25% | 25% | None |
RESCRIPTOR 200 MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
RESERPINE 0.1MG TABLET |
2 |
Non-Preferred Generic |
25% | 25% | P |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
4 |
Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RESTORIL 15mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RESTORIL 22.5mg/1 30 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RESTORIL 30mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RESTORIL 7.5mg/1 30 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RETROVIR 100mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
Revatio 0.8mg/mL 12.5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | 25% | P |
REVATIO 20MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
REVIA 50MG TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
REYATAZ 100MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
REYATAZ 150MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
REYATAZ 200MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
REYATAZ 300MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
RHEUMATREX 2.5MG TABLET DOSE PACK |
4 |
Non-Preferred Brand |
25% | 25% | None |
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY |
3 |
Preferred Brand |
25% | 25% | None |
RIBASPHERE 200MG TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIBASPHERE 400MG TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE 600MG TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIBASPHERE CAPSULES 200MG 42 BOT |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIBASPHERE RibaPak |
4 |
Non-Preferred Brand |
25% | 25% | None |
RIBASPHERE RibaPak 400mg/1 |
4 |
Non-Preferred Brand |
25% | 25% | None |
RIBASPHERE RibaPak 600mg/1 |
4 |
Non-Preferred Brand |
25% | 25% | None |
RIBAVIRIN 200MG CAPSULE |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIBAVIRIN 200MG TABLET 168 BOT |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIDAURA 3MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
RIFADIN 150MG CAPSULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RIFADIN 300MG CAPSULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RIFADIN IV 600MG VIAL |
4 |
Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMATE CAPSULE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIFAMPIN 300MG CAPSULE |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIFAMPIN 600MG VIAL |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIFATER TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RILUTEK 50MG TABLET |
3 |
Preferred Brand |
25% | 25% | P |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
25% | 25% | None |
RINGERS INJECTION 1000ML BAG |
2 |
Non-Preferred Generic |
25% | 25% | None |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIOMET 500MG/5ML SOLUTION ORAL |
3 |
Preferred Brand |
25% | 25% | None |
RISPERDAL 0.25MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL 0.5MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL 1MG M-TAB |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL 1MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL 2MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL 3MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL 4MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL CONSTA 37.5MG SYR |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
25% | 25% | None |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL M TABLET 0.5MG |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL M-TAB 2mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL M-TAB 3mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
25% | 25% | None |
RISPERDAL M-TAB 4mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
25% | 25% | None |
Risperidone 1mg/1 7 BLISTER PACK in 1 CARTON / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
25% | 25% | None |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLET 1 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLET 2 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLET 3 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLET 4 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
2 |
Non-Preferred Generic |
25% | 25% | None |
RISPERIODONE TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
RITALIN 10MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | P |
RITALIN 20MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | P |
RITALIN 5MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | P |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
25% | 25% | None |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
25% | 25% | None |
rizatriptan 10 mg odt |
2 |
Non-Preferred Generic |
25% | 25% | Q:12 /30Days |
rizatriptan 10 mg tablet |
2 |
Non-Preferred Generic |
25% | 25% | Q:12 /30Days |
rizatriptan 5 mg odt |
2 |
Non-Preferred Generic |
25% | 25% | Q:12 /30Days |
rizatriptan 5 mg tablet |
2 |
Non-Preferred Generic |
25% | 25% | Q:12 /30Days |
ROBINUL 1MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
ROBINUL FORTE 2MG TABLET |
4 |
Non-Preferred Brand |
25% | 25% | None |
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | P |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | 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 |
4 |
Non-Preferred Brand |
25% | 25% | P |
ROCEPHIN FOR INJECTION |
4 |
Non-Preferred Brand |
25% | 25% | None |
ROPINIROLE HCL TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROPINIROLE HCL TABLET 1 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROPINIROLE HCL TABLET 2 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROPINIROLE HCL TABLET 3 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROPINIROLE HCL TABLET 4 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROPINIROLE HCL TABLET 5 MG |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROPINIROLE HYDROCLORIDE TABLET |
2 |
Non-Preferred Generic |
25% | 25% | None |
ROTATEQ VACCINE |
4 |
Non-Preferred Brand |
25% | 25% | None |
ROZEREM 8MG TABLET (100 CT) |
3 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RYTHMOL FILM COATED TABLETS 225 MG |
4 |
Non-Preferred Brand |
25% | 25% | None |
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
25% | 25% | None |
RYTHMOL TABLETS |
4 |
Non-Preferred Brand |
25% | 25% | None |