2020 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0)
Benefit Details
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The Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $65.30 Deductible: $100 Qualifies for LIS: No |
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 |
$42.00 | $105.00 | P |
RALOXIFENE HCL 60 MG TABLET [Evista] ![Compare how all Medicare Part D PDP plans in FL cover RALOXIFENE HCL 60 MG TABLET [Evista].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
RAMELTEON 8 MG TABLET [Rozerem] ![Compare how all Medicare Part D PDP plans in FL cover RAMELTEON 8 MG TABLET [Rozerem].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
RAMIPRIL 1.25 MG CAPSULE  |
1* |
Preferred Generic |
$4.00 | $0.00 | None |
RAMIPRIL 10 MG CAPSULE  |
1* |
Preferred Generic |
$4.00 | $0.00 | None |
RAMIPRIL 2.5 MG CAPSULE [Altace] ![Compare how all Medicare Part D PDP plans in FL cover RAMIPRIL 2.5 MG CAPSULE [Altace].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $0.00 | None |
RAMIPRIL 5 MG CAPSULE  |
1* |
Preferred Generic |
$4.00 | $0.00 | None |
RANOLAZINE ER 1,000 MG TABLET 12H [Ranexa] ![Compare how all Medicare Part D PDP plans in FL cover RANOLAZINE ER 1,000 MG TABLET 12H [Ranexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RANOLAZINE ER 500 MG TABLET 12H [Ranexa] ![Compare how all Medicare Part D PDP plans in FL cover RANOLAZINE ER 500 MG TABLET 12H [Ranexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RAPAMUNE 1MG/ML ORAL TUBEX  |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RASAGILINE MESYLATE 0.5 MG TABLET [Azilect] ![Compare how all Medicare Part D PDP plans in FL cover RASAGILINE MESYLATE 0.5 MG TABLET [Azilect].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
RASAGILINE MESYLATE 1 MG TABLET [Azilect] ![Compare how all Medicare Part D PDP plans in FL cover RASAGILINE MESYLATE 1 MG TABLET [Azilect].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS  |
5 |
Specialty Tier |
31% | N/A | P Q:6 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS  |
5 |
Specialty Tier |
31% | N/A | P Q:6 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML  |
5 |
Specialty Tier |
31% | N/A | P Q:6 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML  |
5 |
Specialty Tier |
31% | N/A | P Q:6 /28Days |
REBIF REBIDOSE TITRATION PACK  |
5 |
Specialty Tier |
31% | N/A | P Q:8 /365Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:8 /365Days |
RECLIPSEN 28 DAY TABLET [Solia] ![Compare how all Medicare Part D PDP plans in FL cover RECLIPSEN 28 DAY TABLET [Solia].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR  |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:3 /365Days |
RECOMBIVAX HB 10 MCG/ML VIAL  |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:3 /365Days |
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 |
$42.00 | $105.00 | P Q:3 /365Days |
RECTIV 0.4% OINTMENT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
REGRANEX 0.01% GEL  |
5 |
Specialty Tier |
31% | N/A | P |
RELISTOR 12 MG/0.6 ML SYRINGE  |
5 |
Specialty Tier |
31% | N/A | P |
RELISTOR 12 MG/0.6 ML VIAL  |
5 |
Specialty Tier |
31% | N/A | P |
RELISTOR 8 MG/0.4 ML SYRINGE  |
5 |
Specialty Tier |
31% | N/A | P |
RENVELA 800MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:540 /30Days |
REPAGLINIDE 0.5 MG TABLET [Prandin] ![Compare how all Medicare Part D PDP plans in FL cover REPAGLINIDE 0.5 MG TABLET [Prandin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
REPAGLINIDE 1 MG TABLET [Prandin] ![Compare how all Medicare Part D PDP plans in FL cover REPAGLINIDE 1 MG TABLET [Prandin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
REPAGLINIDE 2 MG TABLET [Prandin] ![Compare how all Medicare Part D PDP plans in FL cover REPAGLINIDE 2 MG TABLET [Prandin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:240 /30Days |
REPATHA 140 MG/ML SURECLICK PEN INJCTR  |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:3 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REPATHA 140 MG/ML SYRINGE  |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:3 /28Days |
REPATHA 420 MG/3.5ML PUSHTRONX WEAR INJCT  |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:4 /28Days |
RESTASIS 0.05% EYE EMULSION  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
RETACRIT 10,000 UNIT/ML VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:12 /28Days |
RETACRIT 2,000 UNIT/ML VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:12 /28Days |
RETACRIT 3,000 UNIT/ML VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:12 /28Days |
RETACRIT 4,000 UNIT/ML VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:12 /28Days |
RETACRIT 40,000 UNIT/ML VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:6 /28Days |
RETEVMO 40 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P |
RETEVMO 80 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P |
REVLIMID 10 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVLIMID 15MG CAPSULE 21 BOT  |
5 |
Specialty Tier |
31% | N/A | P Q:21 /28Days |
REVLIMID 2.5 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:28 /28Days |
REVLIMID 20 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:21 /28Days |
REVLIMID 25 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:21 /28Days |
REVLIMID 5 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:28 /28Days |
REXULTI 0.25 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
REXULTI 0.5 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
REXULTI 1 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
REXULTI 2 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
REXULTI 3 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
REXULTI 4 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REYATAZ 50 MG POWDER PACKET  |
5 |
Specialty Tier |
31% | N/A | Q:180 /30Days |
RHOPRESSA 0.02% OPHTH SOLUTION Drops  |
4 |
Non-Preferred Drug |
50% | 50% | S |
RIBAVIRIN 200 MG CAPSULE  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:168 /28Days |
RIBAVIRIN 200MG TABLET 168 BOT  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] ![Compare how all Medicare Part D PDP plans in FL cover RIFABUTIN 150 MG CAPSULE [Mycobutin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
RIFAMPIN 150 MG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
RIFAMPIN 300 MG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
RIFAMPIN IV 600 MG VIAL [Rifadin] ![Compare how all Medicare Part D PDP plans in FL cover RIFAMPIN IV 600 MG VIAL [Rifadin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
RILUZOLE 50 MG TABLET [Rilutek] ![Compare how all Medicare Part D PDP plans in FL cover RILUZOLE 50 MG TABLET [Rilutek].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE  |
2* |
Generic |
$10.00 | $20.00 | None |
RINVOQ ER 15 MG TABLET ER 24H  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIOMET 500MG/5ML SOLUTION ORAL  |
4 |
Non-Preferred Drug |
50% | 50% | Q:750 /30Days |
RISPERDAL CONSTA 25MG SYR  |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR  |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR  |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /28Days |
RISPERIDONE 0.25 MG TABLET [Risperdal] ![Compare how all Medicare Part D PDP plans in FL cover RISPERIDONE 0.25 MG TABLET [Risperdal].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 0.5 MG ODT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
RISPERIDONE 0.5 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 1 MG ODT TABLET RAPDIS [Risperdal M-Tab] ![Compare how all Medicare Part D PDP plans in FL cover RISPERIDONE 1 MG ODT TABLET RAPDIS [Risperdal M-Tab].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RISPERIDONE 1 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 1 MG/ML SOLUTION  |
4 |
Non-Preferred Drug |
50% | 50% | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 2 MG ODT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RISPERIDONE 2 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 3 MG ODT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RISPERIDONE 3 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE 4 MG ODT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
RISPERIDONE 4 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RITONAVIR 100 MG TABLET [Norvir] ![Compare how all Medicare Part D PDP plans in FL cover RITONAVIR 100 MG TABLET [Norvir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:360 /30Days |
RIVASTIGMINE 1.5 MG CAPSULE [Exelon] ![Compare how all Medicare Part D PDP plans in FL cover RIVASTIGMINE 1.5 MG CAPSULE [Exelon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RIVASTIGMINE 13.3 MG/24HR PTCH  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
RIVASTIGMINE 3 MG CAPSULE [Exelon] ![Compare how all Medicare Part D PDP plans in FL cover RIVASTIGMINE 3 MG CAPSULE [Exelon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 4.5 MG CAPSULE [Exelon] ![Compare how all Medicare Part D PDP plans in FL cover RIVASTIGMINE 4.5 MG CAPSULE [Exelon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RIVASTIGMINE 4.6 MG/24HR PATCH  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
RIVASTIGMINE 6 MG CAPSULE [Exelon] ![Compare how all Medicare Part D PDP plans in FL cover RIVASTIGMINE 6 MG CAPSULE [Exelon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
RIVASTIGMINE 9.5 MG/24HR PATCH  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
RIVELSA TABLET TBDSPK 3MO  |
2* |
Generic |
$10.00 | $20.00 | None |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] ![Compare how all Medicare Part D PDP plans in FL cover RIZATRIPTAN 10 MG ODT [Maxalt-MLT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /28Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] ![Compare how all Medicare Part D PDP plans in FL cover RIZATRIPTAN 10 MG TABLET [Maxalt].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:36 /28Days |
RIZATRIPTAN 5 MG ODT [Maxalt-MLT] ![Compare how all Medicare Part D PDP plans in FL cover RIZATRIPTAN 5 MG ODT [Maxalt-MLT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /28Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] ![Compare how all Medicare Part D PDP plans in FL cover RIZATRIPTAN 5 MG TABLET [Maxalt].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:36 /28Days |
ROCKLATAN 0.02%-0.005% EYE DROPS  |
4 |
Non-Preferred Drug |
50% | 50% | S |
ROPINIROLE HCL 0.25 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 0.5 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL 1 MG TABLET [Requip] ![Compare how all Medicare Part D PDP plans in FL cover ROPINIROLE HCL 1 MG TABLET [Requip].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL 2 MG TABLET [Requip] ![Compare how all Medicare Part D PDP plans in FL cover ROPINIROLE HCL 2 MG TABLET [Requip].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL 3 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL 4 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL 5 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
ROPINIROLE HCL ER 12 MG TABLET ER 24H [Requip XL] ![Compare how all Medicare Part D PDP plans in FL cover ROPINIROLE HCL ER 12 MG TABLET ER 24H [Requip XL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
ROPINIROLE HCL ER 2 MG TABLET ER 24H [Requip XL] ![Compare how all Medicare Part D PDP plans in FL cover ROPINIROLE HCL ER 2 MG TABLET ER 24H [Requip XL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
ROPINIROLE HCL ER 4 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | None |
ROPINIROLE HCL ER 6 MG TABLET ER 24H [Requip XL] ![Compare how all Medicare Part D PDP plans in FL cover ROPINIROLE HCL ER 6 MG TABLET ER 24H [Requip XL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
ROPINIROLE HCL ER 8 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor] ![Compare how all Medicare Part D PDP plans in FL cover ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor] ![Compare how all Medicare Part D PDP plans in FL cover ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 40 MG TABLET [Crestor] ![Compare how all Medicare Part D PDP plans in FL cover ROSUVASTATIN CALCIUM 40 MG TABLET [Crestor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor] ![Compare how all Medicare Part D PDP plans in FL cover ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
ROTARIX VACCINE SUSPENSION  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ROTATEQ VACCINE SOLUTION  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Roweepra 1,000 mg tablet  |
2* |
Generic |
$10.00 | $20.00 | None |
ROWEEPRA 500 MG TABLET  |
2* |
Generic |
$10.00 | $20.00 | None |
Roweepra 750 mg tablet  |
2* |
Generic |
$10.00 | $20.00 | None |
ROWEEPRA XR 500 MG TABLET ER 24H  |
4 |
Non-Preferred Drug |
50% | 50% | None |
ROWEEPRA XR 750 MG TABLET ER 24H  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROZLYTREK 100 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:150 /30Days |
ROZLYTREK 200 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
RUBRACA 200 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
RUBRACA 250 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
RUBRACA 300 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
RUCONEST 2,100 UNIT VIAL  |
5 |
Specialty Tier |
31% | N/A | P Q:8 /30Days |
RYDAPT 25 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:224 /28Days |
RYTARY ER 23.75 MG-95 MG CAP  |
4 |
Non-Preferred Drug |
50% | 50% | S |
RYTARY ER 36.25 MG-145 MG CAP  |
4 |
Non-Preferred Drug |
50% | 50% | S |
RYTARY ER 48.75 MG-195 MG CAP  |
4 |
Non-Preferred Drug |
50% | 50% | S |
RYTARY ER 61.25 MG-245 MG CAP  |
4 |
Non-Preferred Drug |
50% | 50% | S |