2014 Medicare Part D Plan Formulary Information |
Express Scripts Medicare - Choice (PDP) (S5660-195-0)
Benefit Details
|
The Express Scripts Medicare - Choice (PDP) (S5660-195-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $70.60 Deductible: $0 Qualifies for LIS: No |
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] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RAGWITEK SUBLINGUAL TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Raloxifene HCl 60 mg tablet [Evista] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RAMIPRIL 1.25MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RAMIPRIL 10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RAMIPRIL 2.5MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RAMIPRIL 5MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE 150MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
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 |
$2.00 | $0.00 | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE BOTTLE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
RAPAMUNE 0.5MG TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
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 |
5 |
Specialty Tier |
33% | N/A | P |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
33% | N/A | None |
REBETOL 40MG/ML SOLUTION |
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 |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:12 /28Days |
RECLAST 5MG/100ML INJECTION |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RECLIPSEN 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
RECTIV 0.4% OINTMENT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REGRANEX 0.01% GEL |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:45 /90Days |
RELENZA 5MG DISKHALER |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:60 /180Days |
RELISTOR 12 MG/0.6 ML KIT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RELPAX 20MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:54 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELPAX 40MG TABLET 6X2 BLPK |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:54 /84Days |
REMICADE 100MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
REMODULIN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
REMODULIN 1MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
REMODULIN 2.5MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
REMODULIN 5MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
RENVELA 800MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
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 |
Reprexain 10-200 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:150 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
RESERPINE 0.1MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Reserpine 0.25mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:180 /90Days |
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% | N/A | P |
REVATIO 20MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:93 /31Days |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | N/A | None |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
33% | N/A | None |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | N/A | None |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
REYATAZ 100MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
REYATAZ 150MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
RHEUMATREX 2.5MG TABLET DOSE PACK |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
RIBASPHERE 200MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RIBASPHERE 400MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RIBASPHERE 600MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE CAPSULES 200MG 42 BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
33% | N/A | None |
RIBASPHERE RibaPak 400mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
RIBAVIRIN 200 MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RIDAURA 3MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIFAMPIN 300MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
RIFAMPIN 600MG VIAL |
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 |
riluzole 50 mg tablet [Rilutek] |
5 |
Specialty Tier |
33% | N/A | None |
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 |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2295 /90Days |
RISPERDAL CONSTA 25MG SYR |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
33% | N/A | None |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | N/A | None |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
RISPERIDONE 0.25 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:5760 /90Days |
RISPERIDONE 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:2880 /90Days |
RISPERIDONE 1 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:1440 /90Days |
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 |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:1440 /90Days |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:1440 /90Days |
RISPERIDONE 2 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:720 /90Days |
RISPERIDONE 3 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:482 /90Days |
RISPERIDONE 4 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:360 /90Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:5760 /90Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:482 /90Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:360 /90Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:2880 /90Days |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:720 /90Days |
RITALIN LA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RITALIN LA 20MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
RITALIN LA 30MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
RITALIN LA 40MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | 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 |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
rizatriptan 10 mg odt |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:108 /84Days |
rizatriptan 10 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:108 /84Days |
rizatriptan 5 mg odt |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:108 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
rizatriptan 5 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:108 /84Days |
ROPINIROLE HCL 0.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 1 MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 2 MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 3 MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 4 MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 5 MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE TAB 12MG ER |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE TAB 2MG ER |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE TAB 4MG ER |
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 |
ROPINIROLE TAB 6MG ER |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROPINIROLE TAB 8MG ER |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ROTATEQ VACCINE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
ROXICET 5-325/5ML SOLUTION ORAL |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2400 /90Days |
ROZEREM 8MG TABLET (100 CT) |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |