2015 Medicare Part D Plan Formulary Information |
HumanaChoice H5216-003 (PPO) (H5216-003-0)
Benefit Details
|
The HumanaChoice H5216-003 (PPO) (H5216-003-0) Formulary Drugs Starting with the Letter R in WINNEBAGO County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $73.00 Deductible: $320 |
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 |
RABAVERT RABIES VACCINE KIT |
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 |
$15.00 | $0.00 | None |
RAMIPRIL 10MG CAPSULE |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
RAMIPRIL 2.5MG CAPSULE |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
RAMIPRIL 5MG CAPSULE |
2* |
Non-Preferred Generic |
$15.00 | $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 |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
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 300mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
RANITIDINE HCL 150 MG/6 ML VL |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
Ranitidine Hydrochloride 150mg/1 1000 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE BOTTLE |
3* |
Preferred Brand |
$45.00 | $125.00 | 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 |
REBETOL 40MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:1000 /30Days |
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 |
25% | 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 |
25% | N/A | P Q:6 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
REBIF REBIDOSE TITRATION PACK |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
RECLIPSEN 0.15-0.03 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RECOMBIVAX HB 5 MCG/0.5 ML SYR |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:36 /28Days |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:36 /28Days |
RELISTOR 8 MG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:12 /30Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
RESERPINE 0.1MG TABLET |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | P |
Reserpine 0.25mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$15.00 | $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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVATIO 10 MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
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 |
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 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 |
REYATAZ 50 MG POWDER PACKET |
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 |
RHEUMATREX 2.5 MG TABLET 12 EA |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RHEUMATREX 2.5 MG TABLET 16 EA |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RHEUMATREX 2.5 MG TABLET 20 EA |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RHEUMATREX 2.5 MG TABLET 8 EA |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RHEUMATREX 2.5MG TABLET DOSE PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
RIBASPHERE 200MG TABLET |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:168 /28Days |
RIBASPHERE CAPSULES 200MG 42 BOT |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:168 /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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
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 IV 600 MG Vial |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
RIFATER 50/300/120 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | 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 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
RISEDRONATE SODIUM 150 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:1 /30Days |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /28Days |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
RISEDRONATE SODIUM DR 35 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /28Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 0.25 MG TABLET |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 0.5mg/1 500 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | Q:120 /30Days |
RISPERIDONE 0.5mg/1 7 BLISTER PACK in 1 CARTON / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days |
RISPERIDONE 1 MG TABLET |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days |
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 |
3* |
Preferred Brand |
$45.00 | $125.00 | None |
RISPERIDONE 2mg/1 20 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, ORALLY DISINTEGRATING in 1 BLISTE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RISPERIDONE 2mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 3mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 4 MG TABLET |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 | None |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ROPINIROLE HCL 0.5MG TABLET |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
ROPINIROLE HCL TABLET 1 MG |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
ROPINIROLE HCL TABLET 2 MG |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
ROPINIROLE HCL TABLET 3 MG |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
ROPINIROLE HCL TABLET 4 MG |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
ROPINIROLE HCL TABLET 5 MG |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
2* |
Non-Preferred Generic |
$15.00 | $0.00 | None |
ROPINIROLE TAB 12MG ER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
ROPINIROLE TAB 2MG ER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
ROPINIROLE TAB 4MG ER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
ROPINIROLE TAB 6MG ER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
ROPINIROLE TAB 8MG ER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days |
ROTARIX VACCINE SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
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 |