2019 Medicare Part D Plan Formulary Information |
Optimo Plus (PPO) (H4005-004-0)
Benefit Details
|
The Optimo Plus (PPO) (H4005-004-0) Formulary Drugs Starting with the Letter R in Luquillo County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $121.00 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 VIAL |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RALOXIFENE HCL 60 MG TABLET [Evista] |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
RAMIPRIL 1.25 MG CAPSULE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
RAMIPRIL 10 MG CAPSULE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
RAMIPRIL 2.5 MG CAPSULE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
RAMIPRIL 5 MG CAPSULE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
RANEXA ER 1,000 MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
RANEXA ER 500 MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
RANITIDINE 15 MG/ML SYRUP |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RANITIDINE 150 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE 300 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RANOLAZINE ER 1,000 MG TABLET ER 12H [Ranexa] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
RANOLAZINE ER 500 MG TABLET ER 12H [Ranexa] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
RAPAMUNE 0.5MG TABLETS |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
RAPAMUNE 1MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
5 |
Specialty Tier |
25% | 25% | P |
RAPAMUNE 2MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Rasagiline Mesylate 0.5 MG TABLET [Azilect] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
Rasagiline Mesylate 1 MG TABLET [Azilect] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
25% | 25% | P |
RECOMBIVAX HB 10 MCG/ML SYR |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:30 /30Days |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RELISTOR 12 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:18 /30Days |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:18 /30Days |
RELISTOR 150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
RELISTOR 8 MG/0.4 ML SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:12 /30Days |
RELPAX 20MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | S Q:12 /30Days |
RELPAX 40 MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | S Q:6 /30Days |
RENVELA 800MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REPAGLINIDE 1 MG TABLET [Prandin] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
REPAGLINIDE 2 MG TABLET [Prandin] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
REPATHA 140 MG/ML SURECLICK |
5 |
Specialty Tier |
25% | 25% | P |
REPATHA 140 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
REPATHA 420 MG/3.5ML PUSHTRONX |
5 |
Specialty Tier |
25% | 25% | P |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RESTASIS 0.05% EYE EMULSION |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:60 /30Days |
RETACRIT 10,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RETACRIT 2,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RETACRIT 3,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RETACRIT 4,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETACRIT 40,000 UNIT/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
REVLIMID 10 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 25 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
REVLIMID 5 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
REYATAZ 50 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RIBAVIRIN 200 MG CAPSULE |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RIBAVIRIN 200MG TABLET 168 BOT |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RIDAURA 3 MG CAPSULE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
5 |
Specialty Tier |
25% | 25% | None |
RIFAMPIN 150 MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
RIFAMPIN 300 MG 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 |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
RIFATER 50/300/120 TABLET |
5 |
Specialty Tier |
25% | 25% | None |
RILUZOLE 50 MG TABLET [Rilutek] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
RIOMET 500MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RISEDRONATE SODIUM 150 MG TAB [Actonel] |
3 |
Preferred Brand |
$25.00 | $50.00 | S |
RISEDRONATE SODIUM 35 MG TAB [Actonel] |
2 |
Generic |
$10.00 | $20.00 | S |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | S Q:4 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
25% | 25% | S Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
25% | 25% | S Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | S Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 0.25 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
RISPERIDONE 0.5 MG ODT |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days |
RISPERIDONE 0.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
RISPERIDONE 1 MG ODT |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days |
RISPERIDONE 1 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
RISPERIDONE 1 MG/ML SOLUTION |
2 |
Generic |
$10.00 | $20.00 | Q:240 /30Days |
RISPERIDONE 2 MG ODT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:60 /30Days |
RISPERIDONE 2 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
RISPERIDONE 3 MG ODT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:60 /30Days |
RISPERIDONE 3 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
RISPERIDONE 4 MG ODT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | 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 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:60 /30Days |
RITALIN 10MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RITALIN 20MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RITALIN 5MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RITONAVIR 100 MG TABLET [Norvir] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RIVASTIGMINE 1.5 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
RIVASTIGMINE 13.3 MG/24HR PTCH |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RIVASTIGMINE 3 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
RIVASTIGMINE 4.5 MG CAPSULE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
RIVASTIGMINE 4.6 MG/24HR PATCH |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 6 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
RIVASTIGMINE 9.5 MG/24HR PATCH |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
2 |
Generic |
$10.00 | $20.00 | Q:12 /30Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
2 |
Generic |
$10.00 | $20.00 | Q:12 /30Days |
RIZATRIPTAN 5 MG ODT [Maxalt-MLT] |
2 |
Generic |
$10.00 | $20.00 | Q:12 /30Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:12 /30Days |
ROPINIROLE HCL 0.25 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL 0.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL 1 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL 2 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL 3 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 |
ROPINIROLE HCL 4 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROPINIROLE HCL 5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor] |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ROTARIX VACCINE SUSPENSION |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ROTATEQ VACCINE Solution |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ROZEREM 8 MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
RUBRACA 250 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |