2015 Medicare Part D Plan Formulary Information |
Apollo - Constellation Health (HMO) (H8266-001-0)
Benefit Details
|
The Apollo - Constellation Health (HMO) (H8266-001-0) Formulary Drugs Starting with the Letter R in VIEQUES County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 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 |
RABAVERT RABIES VACCINE KIT |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
Raloxifene HCl 60 mg tablet [Evista] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
RAMIPRIL 1.25MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
RANEXA ER 1,000 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RANEXA ER 500 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $15.00 | 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 |
1 |
Generic |
$5.00 | $15.00 | P |
Ranitidine Hydrochloride 150mg/1 1000 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
RAPAMUNE 0.5MG TABLETS |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RAPAMUNE 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RAPAMUNE 2MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RAVICTI 1.1 GRAM/ML LIQUID |
4 |
Specialty Tier |
33% | 33% | P |
RAZADYNE 12MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RAZADYNE 4MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RAZADYNE 8MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RAZADYNE ER 16MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAZADYNE ER 24MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
RAZADYNE ER 8MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
REBETOL 200 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
4 |
Specialty Tier |
33% | 33% | P |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
4 |
Specialty Tier |
33% | 33% | P |
REBIF REBIDOSE 22 MCG/0.5 ML |
4 |
Specialty Tier |
33% | 33% | P |
REBIF REBIDOSE 44 MCG/0.5 ML |
4 |
Specialty Tier |
33% | 33% | P |
REBIF REBIDOSE TITRATION PACK |
4 |
Specialty Tier |
33% | 33% | P |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
4 |
Specialty Tier |
33% | 33% | P |
RECLAST 5MG/100ML INJECTION |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RECLIPSEN 0.15-0.03 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RECOMBIVAX HB 5 MCG/0.5 ML SYR |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RELENZA 5MG DISKHALER |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RELISTOR 12 MG/0.6 ML VIAL |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RELISTOR 8 MG/0.4 ML SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REMERON 15MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
REMERON 30MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
REMERON 45MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
REMERON SLTABLET 45MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMICADE 100MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
RENAGEL 400MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RENAGEL 800MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RENVELA 800MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
Repaglinide 0.5 MG Tablet [Prandin] |
1 |
Generic |
$5.00 | $15.00 | Q:120 /30Days |
Repaglinide 1 MG Tablet [Prandin] |
1 |
Generic |
$5.00 | $15.00 | Q:120 /30Days |
Repaglinide 2 MG Tablet [Prandin] |
1 |
Generic |
$5.00 | $15.00 | Q:240 /30Days |
Reprexain 5-200 mg tablet |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:150 /30Days |
REQUIP 0.25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REQUIP 0.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REQUIP 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 2MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REQUIP 3MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REQUIP 4MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REQUIP 5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RESCRIPTOR 200 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
RESTORIL 15mg/1 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
RESTORIL 22.5mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
RESTORIL 30mg/1 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
RESTORIL 7.5mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETIN-A 0.01% GEL |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RETIN-A 0.025% CREAM |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RETIN-A 0.025% GEL |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RETIN-A 0.05% CREAM |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RETIN-A 0.1% CREAM |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
REVATIO 20MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
REVLIMID 10MG CAPSULE (100 CT) |
4 |
Specialty Tier |
33% | 33% | P |
REVLIMID 15MG CAPSULE 21 BOT |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 2.5 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
REVLIMID 20 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
REVLIMID 25MG CAPSULE (100 CT) |
4 |
Specialty Tier |
33% | 33% | P |
REVLIMID 5MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
REYATAZ 150MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
REYATAZ 200MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
REYATAZ 300MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
REYATAZ 50 MG POWDER PACKET |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
RHEUMATREX 2.5 MG TABLET 12 EA |
1 |
Generic |
$5.00 | $15.00 | None |
RHEUMATREX 2.5 MG TABLET 16 EA |
1 |
Generic |
$5.00 | $15.00 | None |
RHEUMATREX 2.5 MG TABLET 20 EA |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RHEUMATREX 2.5 MG TABLET 8 EA |
1 |
Generic |
$5.00 | $15.00 | None |
RHEUMATREX 2.5MG TABLET DOSE PACK |
1 |
Generic |
$5.00 | $15.00 | None |
RIBAVIRIN 200 MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
1 |
Generic |
$5.00 | $15.00 | None |
RIDAURA 3MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
1 |
Generic |
$5.00 | $15.00 | None |
RIFADIN 150MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RIFADIN 300 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RIFADIN IV 600MG VIAL |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
RIFAMATE 150/300 CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 300MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
Rifampin IV 600 MG Vial |
1 |
Generic |
$5.00 | $15.00 | P |
RIFATER 50/300/120 TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RILUTEK 50 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
riluzole 50 mg tablet [Rilutek] |
1 |
Generic |
$5.00 | $15.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
RINGERS 33/30/860 INJECTION |
1 |
Generic |
$5.00 | $15.00 | P |
RINGERS IRRIGATION 860-30 12X1000ML BAG |
1 |
Generic |
$5.00 | $15.00 | None |
RISPERDAL 0.25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL 0.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL 1MG M-TAB |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL 1MG/ML SOLUTION |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RISPERDAL 2MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL 3mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL 4mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL CONSTA 25MG SYR |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
RISPERDAL CONSTA 37.5MG SYR |
4 |
Specialty Tier |
33% | 33% | None |
RISPERDAL CONSTA 50MG SYR |
4 |
Specialty Tier |
33% | 33% | None |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
RISPERDAL M TABLET 0.5MG |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL M-TAB 2mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL M-TAB 3mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERDAL M-TAB 4mg/1 7 BLISTER PACK in 1 BOX / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:60 /30Days |
RISPERIDONE 0.25 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 0.5mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 0.5mg/1 7 BLISTER PACK in 1 CARTON / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 1 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 1mg/1 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 1mg/mL 30 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
RISPERIDONE 2mg/1 20 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, ORALLY DISINTEGRATING in 1 BLISTE |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 2mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE 3mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 4 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RITALIN 10MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:90 /30Days |
RITALIN 20MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:90 /30Days |
RITALIN 5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:90 /30Days |
RITUXAN 10MG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
RIVASTIGMINE TARTRATE 3MG CAPSULES |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE 4.5MG CAPSULES |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
RIVASTIGMINE TARTRATE 6MG CAPSULES |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
rizatriptan 10 mg odt |
1 |
Generic |
$5.00 | $15.00 | None |
rizatriptan 10 mg tablet |
1 |
Generic |
$5.00 | $15.00 | None |
rizatriptan 5 mg odt |
1 |
Generic |
$5.00 | $15.00 | None |
rizatriptan 5 mg tablet |
1 |
Generic |
$5.00 | $15.00 | None |
ROBINUL 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
ROBINUL FORTE 2MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | P |
ROPINIROLE HCL 0.5MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL TABLET 1 MG |
1 |
Generic |
$5.00 | $15.00 | None |
ROPINIROLE HCL TABLET 2 MG |
1 |
Generic |
$5.00 | $15.00 | None |
ROPINIROLE HCL TABLET 3 MG |
1 |
Generic |
$5.00 | $15.00 | None |
ROPINIROLE HCL TABLET 4 MG |
1 |
Generic |
$5.00 | $15.00 | None |
ROPINIROLE HCL TABLET 5 MG |
1 |
Generic |
$5.00 | $15.00 | None |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ROTARIX VACCINE SUSPENSION |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
ROTATEQ VACCINE |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
ROXICODONE 15 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:180 /30Days |
ROXICODONE 30 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:180 /30Days |
ROXICODONE 5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROZEREM 8MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:30 /30Days |
RYTHMOL 150MG TABLETS |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |
RYTHMOL FILM COATED TABLETS 225 MG |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None |