2016 Medicare Part D Plan Formulary Information |
BlueMedicare HMO MyTime (HMO) (H1026-056-0)
Benefit Details
|
The BlueMedicare HMO MyTime (HMO) (H1026-056-0) Formulary Drugs Starting with the Letter R in Osceola County, FL: CMS MA Region 9 which includes: FL 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 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Rabeprazole Sodium DR 20 MG Tablet [AcipHex] |
2 |
Generic |
$15.00 | $45.00 | Q:30 /30Days |
RAGWITEK SUBLINGUAL TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days |
Raloxifene HCl 60 mg tablet [Evista] |
2 |
Generic |
$15.00 | $45.00 | None |
RAMIPRIL 1.25MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $24.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $24.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $24.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Preferred Generic |
$8.00 | $24.00 | None |
RANEXA ER 1,000 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
RANEXA ER 500 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE 150MG CAPSULE |
2 |
Generic |
$15.00 | $45.00 | None |
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $45.00 | None |
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$8.00 | $24.00 | None |
Ranitidine Hydrochloride 150mg/1 1000 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$8.00 | $24.00 | None |
Ranitidine Hydrochloride 300mg/1 30 CAPSULE BOTTLE |
2 |
Generic |
$15.00 | $45.00 | None |
RAPAFLO CAPSULES 4MG 30 BOT |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
RAPAFLO CAPSULES 8MG 90 BOT |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
RAPAMUNE 1MG/ML ORAL TUBEX |
5 |
Specialty Tier |
33% | N/A | P |
RAZADYNE 12MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RAZADYNE 4MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RAZADYNE 8MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAZADYNE ER 16MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RAZADYNE ER 24MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RAZADYNE ER 8MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REBETOL 40MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RECLIPSEN 0.15-0.03 TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
RECOMBIVAX HB 5 MCG/0.5 ML SYR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
RELISTOR 12 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
RELISTOR 8 MG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMERON 15MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
REMERON 30MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
REMERON 45MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
REMERON SLTABLET 45MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RENVELA 800MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Repaglinide 0.5 MG Tablet [Prandin] |
2 |
Generic |
$15.00 | $45.00 | Q:960 /30Days |
Repaglinide 1 MG Tablet [Prandin] |
2 |
Generic |
$15.00 | $45.00 | Q:480 /30Days |
Repaglinide 2 MG Tablet [Prandin] |
2 |
Generic |
$15.00 | $45.00 | Q:240 /30Days |
REPATHA 140 MG/ML SURECLICK |
5 |
Specialty Tier |
33% | N/A | P Q:3 /30Days |
REPATHA 140 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:3 /30Days |
Reprexain 10-200 mg tablet |
2 |
Generic |
$15.00 | $45.00 | Q:150 /30Days |
REQUIP 0.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REQUIP 0.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REQUIP 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REQUIP 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REQUIP 3MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REQUIP 4MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REQUIP 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:180 /30Days |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
RETIN-A 0.01% GEL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RETIN-A 0.025% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RETIN-A 0.025% GEL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RETIN-A 0.05% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RETIN-A 0.1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 | $285.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:1920 /30Days |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REYATAZ 150MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
REYATAZ 50 MG POWDER PACKET |
5 |
Specialty Tier |
33% | N/A | Q:150 /30Days |
RIBASPHERE 200MG TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
RIBASPHERE 400MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 |
2 |
Generic |
$15.00 | $45.00 | 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 |
2 |
Generic |
$15.00 | $45.00 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
2 |
Generic |
$15.00 | $45.00 | None |
RIDAURA 3MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
2 |
Generic |
$15.00 | $45.00 | None |
RIFADIN 150MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIFADIN 300 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIFADIN IV 600MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
2 |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 300MG CAPSULE |
2 |
Generic |
$15.00 | $45.00 | None |
Rifampin IV 600 MG Vial |
2 |
Generic |
$15.00 | $45.00 | None |
riluzole 50 mg tablet [Rilutek] |
2 |
Generic |
$15.00 | $45.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $45.00 | None |
RISEDRONATE SODIUM 150 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:1 /28Days |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:30 /30Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:4 /28Days |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:30 /30Days |
RISEDRONATE SODIUM DR 35 MG TABLET [Actonel] |
2 |
Generic |
$15.00 | $45.00 | Q:4 /28Days |
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 |
$95.00 | $285.00 | P Q:60 /30Days |
RISPERDAL 0.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days |
RISPERDAL 1MG M-TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days |
RISPERDAL 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days |
RISPERDAL 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:480 /30Days |
RISPERDAL 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days |
RISPERDAL 3mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days |
RISPERDAL 4mg/1 10 BLISTER PACK in 1 BOX, UNIT-DOSE / 10 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:120 /30Days |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:4 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:4 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
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 |
$95.00 | $285.00 | P Q:4 /28Days |
RISPERDAL M TABLET 0.5MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /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 | $285.00 | P 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 | $285.00 | P 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 | $285.00 | P Q:120 /30Days |
RISPERIDONE 0.25 MG TABLET |
1 |
Preferred Generic |
$8.00 | $24.00 | P Q:60 /30Days |
RISPERIDONE 0.5 MG 500 TABLET BOTTLE |
1 |
Preferred Generic |
$8.00 | $24.00 | P Q:60 /30Days |
RISPERIDONE 0.5 MG ODT |
2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days |
RISPERIDONE 1 MG 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days |
RISPERIDONE 1 MG TABLET |
1 |
Preferred Generic |
$8.00 | $24.00 | P Q:60 /30Days |
RISPERIDONE 1 MG/ML 30 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $45.00 | P Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 2 MG 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$8.00 | $24.00 | P Q:60 /30Days |
RISPERIDONE 2 MG ODT |
2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days |
RISPERIDONE 3 MG 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$8.00 | $24.00 | P Q:60 /30Days |
RISPERIDONE 4 MG TABLET |
1 |
Preferred Generic |
$8.00 | $24.00 | P Q:120 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
2 |
Generic |
$15.00 | $45.00 | P Q:120 /30Days |
RITALIN 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
RITALIN 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
RITALIN 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:90 /30Days |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 13.3 MG/24HR PTCH |
2 |
Generic |
$15.00 | $45.00 | None |
RIVASTIGMINE 4.6 MG/24HR PATCH |
2 |
Generic |
$15.00 | $45.00 | None |
RIVASTIGMINE 9.5 MG/24HR PATCH |
2 |
Generic |
$15.00 | $45.00 | None |
RIVASTIGMINE TARTRATE 3MG CAPSULES |
2 |
Generic |
$15.00 | $45.00 | None |
RIVASTIGMINE TARTRATE 4.5MG CAPSULES |
2 |
Generic |
$15.00 | $45.00 | None |
RIVASTIGMINE TARTRATE 6MG CAPSULES |
2 |
Generic |
$15.00 | $45.00 | None |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
2 |
Generic |
$15.00 | $45.00 | None |
Rizatriptan 10 mg odt |
2 |
Generic |
$15.00 | $45.00 | Q:18 /30Days |
Rizatriptan 10 mg tablet |
2 |
Generic |
$15.00 | $45.00 | Q:18 /30Days |
Rizatriptan 5 mg odt |
2 |
Generic |
$15.00 | $45.00 | Q:18 /30Days |
Rizatriptan 5 mg tablet |
2 |
Generic |
$15.00 | $45.00 | Q:18 /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 | $285.00 | None |
ROBINUL FORTE 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
ROPINIROLE HCL 0.5MG TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE HCL TABLET 1 MG |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE HCL TABLET 2 MG |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE HCL TABLET 3 MG |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE HCL TABLET 4 MG |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE HCL TABLET 5 MG |
2 |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE TAB 12MG ER |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE TAB 2MG ER |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE TAB 4MG ER |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE TAB 6MG ER |
2 |
Generic |
$15.00 | $45.00 | None |
ROPINIROLE TAB 8MG ER |
2 |
Generic |
$15.00 | $45.00 | None |
ROTARIX VACCINE SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
ROTATEQ VACCINE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Roweepra 500 mg tablet |
2 |
Generic |
$15.00 | $45.00 | None |
ROXICODONE 15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:180 /30Days |
ROXICODONE 30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROXICODONE 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days |
ROZEREM 8MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days |
RYTHMOL FILM COATED TABLETS 225 MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |