2017 Medicare Part D Plan Formulary Information |
Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0)
Benefit Details
|
The Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0) Formulary Drugs Starting with the Letter R in Los Alamos County, NM: CMS MA Region 20 which includes: NM Plan Monthly Premium: $144.00 Deductible: $400 |
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 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Rabeprazole Sodium DR 20 MG Tablet [AcipHex] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:2 /1Days |
Raloxifene HCl 60 mg tablet [Evista] |
2 |
Generic |
$10.00 | $20.00 | None |
RAMIPRIL 1.25MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
RAMIPRIL 10MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
RAMIPRIL 2.5MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
RAMIPRIL 5MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
RANEXA ER 1,000 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | S Q:2 /1Days |
RANEXA ER 500 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | S Q:2 /1Days |
Ranitidine 15 mg/ml syrup |
2 |
Generic |
$10.00 | $20.00 | 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 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
RANITIDINE HCL 50 MG/2 ML VIAL |
2 |
Generic |
$10.00 | $20.00 | None |
Ranitidine Hydrochloride 150mg/1 1000 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
RAPAMUNE 1MG/ML ORAL TUBEX |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Rasagiline Mesylate 0.5 MG TABLET [Azilect] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:1 /1Days |
Rasagiline Mesylate 1 MG TABLET [Azilect] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:1 /1Days |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
25% | N/A | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | Q:12 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | Q:12 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | Q:12 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REBIF REBIDOSE TITRATION PACK |
5 |
Specialty Tier |
25% | N/A | Q:4 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
25% | N/A | Q:4 /28Days |
RECLIPSEN 0.15-0.03 TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
RECOMBIVAX HB 5 MCG/0.5 ML SYR |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
REGRANEX 0.01% GEL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RELISTOR 12 MG/0.6 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
RELISTOR 12 MG/0.6 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
RELISTOR 8 MG/0.4 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELPAX 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:18 /30Days |
RELPAX 40MG TABLET 6X2 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:18 /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 | $112.50 | None |
Repaglinide 0.5 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Repaglinide 1 MG Tablet [Prandin] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Repaglinide 2 MG Tablet [Prandin] |
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 |
REPAGLINIDE-METFORMIN 1-500 MG [PrandiMet] |
2 |
Generic |
$10.00 | $20.00 | Q:5 /1Days |
REPAGLINIDE-METFORMIN 2-500 MG [PrandiMet] |
2 |
Generic |
$10.00 | $20.00 | Q:5 /1Days |
REPATHA 140 MG/ML SURECLICK |
5 |
Specialty Tier |
25% | N/A | P |
REPATHA 140 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
REPATHA 420 MG/3.5ML PUSHTRONX |
5 |
Specialty Tier |
25% | N/A | P |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
RESCRIPTOR 200 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:2 /1Days |
RETROVIR 200 MG/20 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
REVLIMID 10MG CAPSULE (100 CT) |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REVLIMID 25MG CAPSULE (100 CT) |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REVLIMID 5MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
REYATAZ 150MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
REYATAZ 50 MG POWDER PACKET |
5 |
Specialty Tier |
25% | N/A | None |
RIBASPHERE 200 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
RIBASPHERE 200MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
RIBAVIRIN 200 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
2 |
Generic |
$10.00 | $20.00 | None |
RIDAURA 3 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIFAMPIN 150MG CAPSULE (30 CT) |
2 |
Generic |
$10.00 | $20.00 | None |
RIFAMPIN 300MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Rifampin IV 600 MG Vial |
2 |
Generic |
$10.00 | $20.00 | None |
RIFATER 50/300/120 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
riluzole 50 mg tablet [Rilutek] |
2 |
Generic |
$10.00 | $20.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
RISEDRONATE SODIUM 150 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISEDRONATE SODIUM DR 35 MG TABLET [Actonel] |
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 |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
25% | N/A | None |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
25% | N/A | None |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERIDONE 0.25 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 0.5 MG 500 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 0.5 MG ODT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERIDONE 1 MG 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERIDONE 1 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 1 MG/ML 30 mL in 1 BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 2 MG 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 2 MG ODT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERIDONE 3 MG 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 4 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RITUXAN 10MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
RIVASTIGMINE 13.3 MG/24HR PTCH |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIVASTIGMINE 4.6 MG/24HR PATCH |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIVASTIGMINE 9.5 MG/24HR PATCH |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
RIVASTIGMINE TARTRATE 3MG CAPSULES |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE TARTRATE 4.5MG CAPSULES |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
RIVASTIGMINE TARTRATE 6MG CAPSULES |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
RIVASTIGMINE TARTRATE1.5MG CAPSULES |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
Rizatriptan 10 mg odt |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:18 /30Days |
Rizatriptan 10 mg tablet |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:18 /30Days |
Rizatriptan 5 mg odt |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:18 /30Days |
Rizatriptan 5 mg tablet |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:18 /30Days |
ROPINIROLE HCL 0.5MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 1 MG |
2 |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 2 MG |
2 |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 3 MG |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL TABLET 4 MG |
2 |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL TABLET 5 MG |
2 |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HYDROCLORIDE 0.25MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Rosuvastatin calcium 40 MG TABLET [Crestor] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
ROTARIX VACCINE SUSPENSION |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
ROTATEQ VACCINE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Roweepra 1,000 mg tablet |
2 |
Generic |
$10.00 | $20.00 | None |
Roweepra 500 mg tablet |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Roweepra 750 mg tablet |
2 |
Generic |
$10.00 | $20.00 | None |
ROZEREM 8MG TABLET (100 CT) |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:1 /1Days |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |