2014 Medicare Part D Plan Formulary Information |
AARP MedicareRx Enhanced (PDP) (S5921-323-0)
Benefit Details
|
The AARP MedicareRx Enhanced (PDP) (S5921-323-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 20 which includes: MS Plan Monthly Premium: $97.20 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 |
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
Raloxifene HCl 60 mg tablet [Evista] |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RAMIPRIL 1.25MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RAMIPRIL 10MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RAMIPRIL 2.5MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RAMIPRIL 5MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RANEXA ER 1,000 MG TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | S |
RANEXA ER 500 MG TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | S |
RANITIDINE 150MG CAPSULE |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RANITIDINE HCL 150 MG/6 ML VL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RANITIDINE TABLET USP 150MG (500 CT) |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RAPAFLO CAPSULES 8MG 90 BOT |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RAPAMUNE 0.5MG TABLETS |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | 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 |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAYOS DR 1 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAYOS DR 2 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAYOS DR 5 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE 12MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE 4MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE 8MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE ER 16MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE ER 24MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE ER 8MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RAZADYNE SOL 4MG/ML |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REBETOL 200 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$50.00 | $135.00 | P |
RECLIPSEN 0.15-0.03 TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$30.00 | $75.00 | P |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
33% | 33% | P |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RELISTOR 12 MG/0.6 ML KIT |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RELPAX 20MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELPAX 40MG TABLET 6X2 BLPK |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | S |
REMERON 15MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REMERON 30MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REMERON 45MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REMERON SLTABLET 45MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMODULIN 5MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
RENAGEL 400MG TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | S |
RENAGEL 800MG TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | S |
RENVELA 800MG TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
Repaglinide 0.5 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Repaglinide 1 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Repaglinide 2 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Reprexain 10-200 mg tablet |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | Q:150 /30Days |
Reprexain 2.5-200 mg tablet |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | Q:150 /30Days |
Reprexain 5-200 mg tablet |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | Q:150 /30Days |
REQUIP 0.25MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 0.5MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP 1MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP 2MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP 3MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP 4MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP 5MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP XL 2mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP XL 4mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP XL 6mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP XL 8mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
REQUIP XL TABLET 12 MG |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RESERPINE 0.1MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
Reserpine 0.25mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RETIN A CREAM |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RETIN-A 0.01% GEL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RETIN-A 0.025% CREAM |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RETIN-A 0.025% GEL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RETIN-A 0.05% CREAM |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RETIN-A MICRO 0.04% GEL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETIN-A MICRO 0.1% GEL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | 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 |
REVIA 50MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
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 |
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 |
33% | 33% | P |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
REYATAZ 100MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | 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 |
RHEUMATREX 2.5MG TABLET DOSE PACK |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RIBASPHERE 200MG TABLET |
3 |
Preferred Brand |
$30.00 | $75.00 | P |
RIBASPHERE 400MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
RIBASPHERE 600MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
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 |
$30.00 | $75.00 | P |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
33% | 33% | P |
RIBASPHERE RibaPak 400mg/1 |
5 |
Specialty Tier |
33% | 33% | P |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
33% | 33% | P |
RIBAVIRIN 200 MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | P |
RIBAVIRIN 200MG TABLET 168 BOT |
3 |
Preferred Brand |
$30.00 | $75.00 | P |
RIDAURA 3MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RIFADIN 150MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RIFADIN 300 MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RIFADIN IV 600MG VIAL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMATE 150/300 CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RIFAMPIN 300MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RIFAMPIN 600MG VIAL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RIFATER 50/300/120 TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RILUTEK 50 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
riluzole 50 mg tablet [Rilutek] |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RINGERS 33/30/860 INJECTION |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RIOMET 500MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL 0.25MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 0.5MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 1MG M-TAB |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 1MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 2MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 3MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL 4MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
33% | 33% | None |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | 33% | None |
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 |
$50.00 | $135.00 | None |
RISPERDAL M TABLET 0.5MG |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL M-TAB 2mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL M-TAB 3mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERDAL M-TAB 4mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RISPERIDONE 0.25 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RISPERIDONE 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RISPERIDONE 1 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
Risperidone 1mg/1 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
Risperidone 1mg/mL 30 mL in 1 BOTTLE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RISPERIDONE 2 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 3 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RISPERIDONE 4 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RITALIN 10MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RITALIN 20MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RITALIN 5MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RITALIN LA 10MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | 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 |
$50.00 | $135.00 | None |
RITALIN LA 30MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RITALIN LA 40MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RITALIN-SR 20MG TABLET SA |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
RIVASTIGMINE TARTRATE 3MG CAPSULES |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RIVASTIGMINE TARTRATE 4.5MG CAPSULES |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RIVASTIGMINE TARTRATE 6MG CAPSULES |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
rizatriptan 10 mg odt |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
rizatriptan 10 mg tablet |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
rizatriptan 5 mg odt |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
rizatriptan 5 mg tablet |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
ROBINUL 1MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROBINUL FORTE 2MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | P |
ROCEPHIN 500MG/VIAL FOR INJECTION |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROPINIROLE HCL 0.5MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
ROPINIROLE HCL TABLET 1 MG |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
ROPINIROLE HCL TABLET 2 MG |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL TABLET 3 MG |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
ROPINIROLE HCL TABLET 4 MG |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
ROPINIROLE HCL TABLET 5 MG |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $5.00 | None |
ROPINIROLE TAB 12MG ER |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROPINIROLE TAB 2MG ER |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROPINIROLE TAB 4MG ER |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROPINIROLE TAB 6MG ER |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROPINIROLE TAB 8MG ER |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROTATEQ VACCINE |
3 |
Preferred Brand |
$30.00 | $75.00 | None |
ROXICET 5-325/5ML SOLUTION ORAL |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | Q:1800 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROXICODONE 15 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROXICODONE 30 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROXICODONE 5 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
ROZEREM 8MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RYTHMOL 150MG TABLETS |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RYTHMOL FILM COATED TABLETS 225 MG |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $135.00 | None |