2014 Medicare Part D Plan Formulary Information |
AHM Opal (HMO-POS) (H5774-014-0)
Benefit Details
|
The AHM Opal (HMO-POS) (H5774-014-0) Formulary Drugs Starting with the Letter R in TRUJILLO ALTO County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $33.00 Deductible: $0 |
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 |
$70.00 | $140.00 | None |
Raloxifene HCl 60 mg tablet [Evista] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RAMIPRIL 1.25MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RANEXA ER 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RANEXA ER 500 MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE HCL 150 MG/6 ML VL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RAPAMUNE 0.5MG TABLETS |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RAPAMUNE 1MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
5 |
Specialty Tier |
33% | 33% | P |
RAPAMUNE 2MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
RAZADYNE 12MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RAZADYNE 4MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RAZADYNE 8MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RAZADYNE ER 16MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RAZADYNE ER 24MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAZADYNE ER 8MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RAZADYNE SOL 4MG/ML |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REBETOL 200 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
REBETOL 40MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | P |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per 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 5MG/100ML INJECTION |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P Q:100 /365Days |
RECLIPSEN 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RELENZA 5MG DISKHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | 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 |
$70.00 | $140.00 | P Q:18 /30Days |
RELPAX 20MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S Q:12 /30Days |
RELPAX 40MG TABLET 6X2 BLPK |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S Q:6 /30Days |
REMERON 15MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REMERON 30MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REMERON 45MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REMERON SLTABLET 45MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REMICADE 100MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
RENVELA 800MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Repaglinide 0.5 MG Tablet [Prandin] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Repaglinide 1 MG Tablet [Prandin] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Repaglinide 2 MG Tablet [Prandin] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
REQUIP 0.25MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
REQUIP 0.5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
REQUIP 1MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
REQUIP 2MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
REQUIP 3MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
REQUIP 4MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
REQUIP 5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | S |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:64 /30Days |
RETIN A CREAM |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RETIN-A 0.01% GEL |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RETIN-A 0.025% CREAM |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RETIN-A 0.025% GEL |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RETIN-A 0.05% CREAM |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
REVATIO 20MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | 33% | P |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
REYATAZ 100MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
REYATAZ 150MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
RIBASPHERE 200MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE 400MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RIBASPHERE 600MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
RIBASPHERE CAPSULES 200MG 42 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
33% | 33% | None |
RIBASPHERE RibaPak 400mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
RIBAVIRIN 200 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
RIBAVIRIN 200MG TABLET 168 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
RIDAURA 3MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 300MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIFAMPIN 600MG VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIFATER 50/300/120 TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RILUTEK 50 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
riluzole 50 mg tablet [Rilutek] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RINGERS 33/30/860 INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIOMET 500MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | Q:8 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
33% | 33% | Q:6 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | 33% | Q:4 /28Days |
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 |
Non-Preferred Brand |
$70.00 | $140.00 | Q:16 /28Days |
RISPERIDONE 0.25 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RISPERIDONE 0.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RISPERIDONE 1 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Risperidone 1mg/1 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RISPERIDONE 2 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RISPERIDONE 3 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RISPERIDONE 4 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RITALIN 10MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RITALIN 20MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RITALIN 5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RITALIN-SR 20MG TABLET SA |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
RIVASTIGMINE TARTRATE 3MG CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIVASTIGMINE TARTRATE 4.5MG CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIVASTIGMINE TARTRATE 6MG CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
rizatriptan 10 mg odt |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
rizatriptan 10 mg tablet |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
rizatriptan 5 mg odt |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
rizatriptan 5 mg tablet |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROBINUL 1MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
ROBINUL FORTE 2MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
ROPINIROLE HCL 0.5MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 1 MG |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Preferred Generic |
$5.00 | $10.00 | 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 |
$5.00 | $10.00 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROTATEQ VACCINE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RYTHMOL 150MG TABLETS |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
RYTHMOL FILM COATED TABLETS 225 MG |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |