2013 Medicare Part D Plan Formulary Information |
Blue Medicare PPO Enhanced (PPO) (H3404-001-0)
Benefit Details
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The Blue Medicare PPO Enhanced (PPO) (H3404-001-0) Formulary Drugs Starting with the Letter R in RICHMOND County, NC: CMS MA Region 7 which includes: NC
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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 |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
RAMIPRIL 1.25MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RANEXA ER 1,000 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RANEXA ER 500 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RANITIDINE 150MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE HCL 25MG/ML VIAL |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days |
RAPAFLO CAPSULES 8MG 90 BOT |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days |
RAPAMUNE 1MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
RAPAMUNE 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
RAPAMUNE TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
RAYOS DR 1 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RAYOS DR 2 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAYOS DR 5 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
REBETOL 40MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS in 1 CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS in 1 CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
33% | 33% | P |
RECLAST INJECTION |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RECLIPSEN 0.15-0.03 TABLET |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
Regonol 5mg/mL 10 AMPULE in 1 CARTON / 2 mL in 1 AMPULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REGRANEX 0.01% GEL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELISTOR 12 MG/0.6 ML KIT |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
RELPAX 20MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | S Q:16 /30Days |
RELPAX 40MG TABLET 6X2 BLPK |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | S Q:8 /30Days |
REMICADE 100MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
REMODULIN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
REMODULIN 1MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
REMODULIN 2.5MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
REMODULIN 5MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
RENAGEL 400MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RENAGEL 800MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RENVELA 800MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
reprexain 10-200 mg tablet |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:180 /30Days |
reprexain 2.5-200 mg tablet |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:360 /30Days |
reprexain 5-200 mg tablet |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:360 /30Days |
REQUIP XL 2mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REQUIP XL 4mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REQUIP XL 6mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REQUIP XL 8mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REQUIP XL TABLET 12 MG |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RESCRIPTOR 200 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RESCULA 0.15% EYE DROPS |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RESERPINE 0.1MG TABLET |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
Reserpine 0.25mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P |
RETIN-A MICRO 0.04% GEL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RETIN-A MICRO 0.1% GEL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Revatio 0.8mg/mL 12.5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | 33% | P |
REVATIO 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
REYATAZ 100MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
REYATAZ 150MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
RHEUMATREX 2.5MG TABLET DOSE PACK |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RIBASPHERE 200MG TABLET |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIBASPHERE 400MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RIBASPHERE 600MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
RIBASPHERE CAPSULES 200MG 42 BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE RibaPak 400mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
RIBAVIRIN 200MG CAPSULE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIDAURA 3MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIFAMPIN 300MG CAPSULE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIFAMPIN 600MG VIAL |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
RIFATER TABLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None |
RILUTEK 50MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RINGERS INJECTION 1000ML BAG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
RIOMET 500MG/5ML SOLUTION ORAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
33% | 33% | P Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | 33% | P Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | P Q:2 /28Days |
Risperidone 1mg/1 7 BLISTER PACK in 1 CARTON / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:60 /30Days |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:480 /30Days |
RISPERIDONE TABLET |
1 |
Preferred Generic |
$8.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLET 1 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE TABLET 2 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE TABLET 3 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE TABLET 4 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | P Q:120 /30Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:60 /30Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:120 /30Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:60 /30Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | P Q:60 /30Days |
RISPERIODONE TABLET |
1 |
Preferred Generic |
$8.00 | $0.00 | P Q:60 /30Days |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:60 /30Days |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:60 /30Days |
RIVASTIGMINE TARTRATE CAPSULES |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:60 /30Days |
rizatriptan 10 mg odt |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:12 /30Days |
rizatriptan 10 mg tablet |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:12 /30Days |
rizatriptan 5 mg odt |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:24 /30Days |
rizatriptan 5 mg tablet |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | Q:24 /30Days |
ROPINIROLE HCL TABLET |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
ROPINIROLE HCL TABLET 1 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL TABLET 4 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
ROPINIROLE HYDROCLORIDE TABLET |
1 |
Preferred Generic |
$8.00 | $0.00 | None |
ROPINIROLE TAB 12MG ER |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
ROPINIROLE TAB 2MG ER |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
ROPINIROLE TAB 4MG ER |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
ROPINIROLE TAB 6MG ER |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
ROPINIROLE TAB 8MG ER |
2 |
Non-Preferred Generic |
$25.00 | $62.50 | None |
ROTATEQ VACCINE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
ROXICET 5-325/5ML SOLUTION ORAL |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:1800 /30Days |
ROXICET 5/500 CAPLET |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROZEREM 8MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | S Q:30 /30Days |