2014 Medicare Part D Plan Formulary Information |
HumanaChoice H5868-009 (PPO) (H5868-009-0)
Benefit Details
|
The HumanaChoice H5868-009 (PPO) (H5868-009-0) Formulary Drugs Starting with the Letter R in IDA County, IA: CMS MA Region 19 which includes: IA Plan Monthly Premium: $56.00 Deductible: $310 |
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 |
Rabeprazole Sodium DR 20 MG Tablet [AcipHex] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:30 /30Days |
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL |
3* |
Preferred Brand |
$45.00 | $125.00 | P |
Raloxifene HCl 60 mg tablet [Evista] |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
RAMIPRIL 1.25MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RAMIPRIL 10MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RAMIPRIL 2.5MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RAMIPRIL 5MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RANEXA ER 1,000 MG TABLET |
3* |
Preferred Brand |
$45.00 | $125.00 | S Q:120 /30Days |
RANEXA ER 500 MG TABLET |
3* |
Preferred Brand |
$45.00 | $125.00 | S Q:120 /30Days |
RANITIDINE 150MG CAPSULE |
3* |
Preferred Brand |
$45.00 | $125.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RANITIDINE HCL 150 MG/6 ML VL |
1* |
Preferred Generic |
$5.00 | $0.00 | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE BOTTLE |
3* |
Preferred Brand |
$45.00 | $125.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
RAPAFLO CAPSULES 8MG 90 BOT |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
RAPAMUNE 0.5MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RAPAMUNE 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RAPAMUNE 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REBETOL 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:168 /28Days |
REBETOL 40MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:1000 /30Days |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
RECLIPSEN 0.15-0.03 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
25% | N/A | None |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /180Days |
RELISTOR 12 MG/0.6 ML KIT |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:36 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMICADE 100MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
REMODULIN 10MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
REMODULIN 1MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
REMODULIN 2.5MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
REMODULIN 5MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
RENVELA 800MG TABLET |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:540 /30Days |
Repaglinide 0.5 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Repaglinide 1 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Repaglinide 2 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:360 /30Days |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RESERPINE 0.1MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | P |
Reserpine 0.25mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | P |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:180 /30Days |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:1680 /28Days |
REVIA 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
REYATAZ 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days |
REYATAZ 150MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
RHEUMATREX 2.5MG TABLET DOSE PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RIBASPHERE 200MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:168 /28Days |
RIBASPHERE 400MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:112 /30Days |
RIBASPHERE 600MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
RIBASPHERE CAPSULES 200MG 42 BOT |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:168 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
25% | N/A | Q:112 /30Days |
RIBASPHERE RibaPak 400mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
25% | N/A | Q:56 /28Days |
RIBAVIRIN 200 MG CAPSULE |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:168 /28Days |
RIBAVIRIN 200MG TABLET 168 BOT |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:168 /28Days |
RIDAURA 3MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RIFADIN 150MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RIFADIN 300 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RIFADIN IV 600MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RIFAMATE 150/300 CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 150MG CAPSULE (30 CT) |
3* |
Preferred Brand |
$45.00 | $125.00 | None |
RIFAMPIN 300MG CAPSULE |
3* |
Preferred Brand |
$45.00 | $125.00 | None |
RIFAMPIN 600MG VIAL |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RIFATER 50/300/120 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RILUTEK 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
riluzole 50 mg tablet [Rilutek] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
3* |
Preferred Brand |
$45.00 | $125.00 | None |
RINGERS 33/30/860 INJECTION |
1* |
Preferred Generic |
$5.00 | $0.00 | None |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
1* |
Preferred Generic |
$5.00 | $0.00 | None |
RIOMET 500MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RISPERDAL 1MG M-TAB |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:4 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:2 /28Days |
RISPERDAL M TABLET 0.5MG |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days |
RISPERDAL M-TAB 2mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RISPERDAL M-TAB 3mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RISPERDAL M-TAB 4mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RISPERIDONE 0.25 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 0.5 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:120 /30Days |
RISPERIDONE 1 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Risperidone 1mg/1 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
RISPERIDONE 2 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 3 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 4 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:120 /30Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE 3MG CAPSULES |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
RIVASTIGMINE TARTRATE 4.5MG CAPSULES |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE 6MG CAPSULES |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
rizatriptan 10 mg odt |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:12 /30Days |
rizatriptan 10 mg tablet |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:12 /30Days |
rizatriptan 5 mg odt |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:12 /30Days |
rizatriptan 5 mg tablet |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:12 /30Days |
ROBINUL 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ROBINUL FORTE 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
ROPINIROLE HCL 0.5MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE HCL TABLET 1 MG |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE HCL TABLET 2 MG |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE HCL TABLET 3 MG |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE HCL TABLET 4 MG |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE HCL TABLET 5 MG |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $0.00 | None |
ROPINIROLE TAB 12MG ER |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
ROPINIROLE TAB 2MG ER |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE TAB 4MG ER |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
ROPINIROLE TAB 6MG ER |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
ROPINIROLE TAB 8MG ER |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
ROTATEQ VACCINE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ROXICET 5-325/5ML SOLUTION ORAL |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:1830 /30Days |