2019 Medicare Part D Plan Formulary Information |
HumanaChoice H5216-083 (PPO) (H5216-083-0)
Benefit Details
|
The HumanaChoice H5216-083 (PPO) (H5216-083-0) Formulary Drugs Starting with the Letter R in Poinsett County, AR: CMS MA Region 15 which includes: AR Plan Monthly Premium: $75.00 Deductible: $195 |
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 |
$47.00 | $131.00 | P |
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
RALOXIFENE HCL 60 MG TABLET [Evista] |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
RAMIPRIL 1.25 MG CAPSULE |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
RAMIPRIL 10 MG CAPSULE |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
RAMIPRIL 2.5 MG CAPSULE |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
RAMIPRIL 5 MG CAPSULE |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
RANEXA ER 1,000 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | S Q:120 /30Days |
RANEXA ER 500 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | S Q:120 /30Days |
RANITIDINE 15 MG/ML SYRUP |
2* |
Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE 150 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
RANITIDINE 150 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
RANITIDINE 300 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
RANITIDINE 300 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
RANOLAZINE ER 1,000 MG TABLET ER 12H [Ranexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | S Q:120 /30Days |
RANOLAZINE ER 500 MG TABLET ER 12H [Ranexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | S Q:120 /30Days |
RAPAFLO 4 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
RAPAFLO 8 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
RAPAMUNE 0.5MG TABLETS |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
RAPAMUNE 1MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAPAMUNE 2MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
Rasagiline Mesylate 0.5 MG TABLET [Azilect] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Rasagiline Mesylate 1 MG TABLET [Azilect] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
RECLIPSEN 28 DAY TABLET [Solia] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
29% | N/A | None |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /180Days |
RELISTOR 12 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:36 /28Days |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:36 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELISTOR 150 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:90 /30Days |
RELISTOR 8 MG/0.4 ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:12 /30Days |
RELPAX 20MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:9 /30Days |
RELPAX 40 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:9 /30Days |
RENAGEL 800MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S |
RENVELA 800MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:540 /30Days |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
REPAGLINIDE 1 MG TABLET [Prandin] |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
REPAGLINIDE 2 MG TABLET [Prandin] |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
REPATHA 140 MG/ML SURECLICK |
5 |
Specialty Tier |
29% | N/A | P Q:3 /28Days |
REPATHA 140 MG/ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | P Q:3 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REPATHA 420 MG/3.5ML PUSHTRONX |
5 |
Specialty Tier |
29% | N/A | P Q:4 /28Days |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:180 /30Days |
RESTASIS 0.05% EYE EMULSION |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
RETACRIT 10,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
RETACRIT 2,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
RETACRIT 3,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
RETACRIT 4,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
RETACRIT 40,000 UNIT/ML VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:14 /30Days |
REVATIO 10 MG/ML ORAL SUSP |
5 |
Specialty Tier |
29% | N/A | P Q:180 /30Days |
REVLIMID 10 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
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 |
29% | N/A | P Q:28 /28Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
REVLIMID 25 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
REVLIMID 5 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
REYATAZ 50 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
29% | N/A | Q:112 /30Days |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
29% | N/A | Q:56 /28Days |
RIBAVIRIN 200 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:168 /28Days |
RIBAVIRIN 200MG TABLET 168 BOT |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:168 /28Days |
RIDAURA 3 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
RIFAMPIN 150 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
RIFAMPIN 300 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
RIFAMPIN IV 600 MG VIAL |
5 |
Specialty Tier |
29% | N/A | None |
RIFATER 50/300/120 TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
RILUZOLE 50 MG TABLET [Rilutek] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Rimantadine 100mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
RISEDRONATE SOD DR 35 MG TABLET DR [Atelvia] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:4 /28Days |
RISEDRONATE SODIUM 150 MG TAB [Actonel] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:1 /30Days |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
RISEDRONATE SODIUM 35 MG TAB [Actonel] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:4 /28Days |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
29% | N/A | Q:2 /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 Drug |
$99.00 | $287.00 | Q:2 /28Days |
RISPERIDONE 0.25 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 0.5 MG ODT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:120 /30Days |
RISPERIDONE 0.5 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:120 /30Days |
RISPERIDONE 1 MG ODT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RISPERIDONE 1 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 1 MG/ML SOLUTION |
2* |
Generic |
$15.00 | $0.00 | None |
RISPERIDONE 2 MG ODT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RISPERIDONE 2 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 3 MG ODT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RISPERIDONE 3 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 4 MG ODT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RISPERIDONE 4 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RITONAVIR 100 MG TABLET [Norvir] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:360 /30Days |
RIVASTIGMINE 1.5 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:90 /30Days |
RIVASTIGMINE 13.3 MG/24HR PTCH |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
RIVASTIGMINE 3 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:90 /30Days |
RIVASTIGMINE 4.5 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RIVASTIGMINE 4.6 MG/24HR PATCH |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
RIVASTIGMINE 6 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
RIVASTIGMINE 9.5 MG/24HR PATCH |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVELSA TABLET TBDSPK 3MO |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:91 /90Days |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:12 /30Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
2* |
Generic |
$15.00 | $0.00 | Q:12 /30Days |
RIZATRIPTAN 5 MG ODT [Maxalt-MLT] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:12 /30Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
2* |
Generic |
$15.00 | $0.00 | Q:12 /30Days |
ROPINIROLE HCL 0.25 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:180 /30Days |
ROPINIROLE HCL 0.5 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:90 /30Days |
ROPINIROLE HCL 1 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:90 /30Days |
ROPINIROLE HCL 2 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:90 /30Days |
ROPINIROLE HCL 3 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:180 /30Days |
ROPINIROLE HCL 4 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL 5 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:30 /30Days |
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:30 /30Days |
ROTARIX VACCINE SUSPENSION |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ROTATEQ VACCINE Solution |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Roweepra 1,000 mg tablet |
2* |
Generic |
$15.00 | $0.00 | None |
ROWEEPRA 500 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
Roweepra 750 mg tablet |
2* |
Generic |
$15.00 | $0.00 | None |
ROWEEPRA XR 500 MG TABLET ER 24H |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROWEEPRA XR 750 MG TABLET ER 24H |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:120 /30Days |
RUBRACA 250 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:120 /30Days |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:120 /30Days |
RUCONEST 2,100 UNIT VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:224 /28Days |
RYTARY ER 23.75 MG-95 MG CAP |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:360 /30Days |
RYTARY ER 36.25 MG-145 MG CAP |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:270 /30Days |
RYTARY ER 48.75 MG-195 MG CAP |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:360 /30Days |
RYTARY ER 61.25 MG-245 MG CAP |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:300 /30Days |