2021 Medicare Part D Plan Formulary Information |
BlueMedicare Complete (HMO D-SNP) (H1035-030-0)
Benefit Details
|
The BlueMedicare Complete (HMO D-SNP) (H1035-030-0) Formulary Drugs Starting with the Letter R in Hillsborough County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $30.80 Deductible: $445 |
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 |
$40.00 | $120.00 | P |
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex] |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
RALOXIFENE HCL 60 MG TABLET [Evista] |
2* |
Generic |
$0.00 | $0.00 | None |
RAMELTEON 8 MG TABLET [Rozerem] |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
RAMIPRIL 1.25 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
RAMIPRIL 10 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
RAMIPRIL 2.5 MG CAPSULE [Altace] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
RAMIPRIL 5 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
RANEXA ER 1,000 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:60 /30Days |
RANEXA ER 500 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANOLAZINE ER 1,000 MG TABLET 12H [Ranexa] |
2* |
Generic |
$0.00 | $0.00 | Q:60 /30Days |
RANOLAZINE ER 500 MG TABLET 12H [Ranexa] |
2* |
Generic |
$0.00 | $0.00 | Q:60 /30Days |
RAPAFLO 4 MG CAPSULE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
RAPAFLO 8 MG CAPSULE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
RAPAMUNE 1MG/ML ORAL TUBEX |
5 |
Specialty Tier |
25% | N/A | P |
RASAGILINE MESYLATE 0.5 MG TABLET [Azilect] |
2* |
Generic |
$0.00 | $0.00 | None |
RASAGILINE MESYLATE 1 MG TABLET [Azilect] |
2* |
Generic |
$0.00 | $0.00 | None |
RAZADYNE ER 16MG CAPSULE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RAZADYNE ER 24MG CAPSULE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RAZADYNE ER 8MG CAPSULE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
REBIF REBIDOSE TITRATION PACK |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
RECLIPSEN 28 DAY TABLET [Solia] |
2* |
Generic |
$0.00 | $0.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
RECOMBIVAX HB 10 MCG/ML VIAL |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
REGLAN 10 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REGLAN 5 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
25% | N/A | P Q:15 /30Days |
RELENZA 5MG DISKHALER |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:120 /365Days |
RELISTOR 12 MG/0.6 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
RELISTOR 12 MG/0.6 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
RELISTOR 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
RELISTOR 8 MG/0.4 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
REMERON 15 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:45 /30Days |
REMERON 30 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMERON SLTABLET 45MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
RENVELA 800MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:270 /30Days |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:960 /30Days |
REPAGLINIDE 1 MG TABLET [Prandin] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:480 /30Days |
REPAGLINIDE 2 MG TABLET [Prandin] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:240 /30Days |
REPATHA 140 MG/ML SURECLICK PEN INJCTR |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:2 /28Days |
REPATHA 140 MG/ML SYRINGE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:2 /28Days |
REPATHA 420 MG/3.5ML PUSHTRONX WEAR INJCT |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:7 /28Days |
RESTASIS 0.05% EYE EMULSION |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:60 /30Days |
RETACRIT 10,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETACRIT 2,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETACRIT 20,000 UNIT/2 ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETACRIT 20,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETACRIT 3,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETACRIT 4,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETACRIT 40,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETEVMO 40 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
RETEVMO 80 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
RETIN-A 0.01% GEL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETIN-A 0.025% GEL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETIN-A 0.1% CREAM (g) |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P |
RETROVIR 100mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:1920 /30Days |
REVLIMID 10 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
REVLIMID 25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
REVLIMID 5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REYATAZ 150MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
REYATAZ 200MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
REYATAZ 300MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
REYATAZ 50 MG POWDER PACKET |
5 |
Specialty Tier |
25% | N/A | Q:240 /30Days |
RHOPRESSA 0.02% OPHTH SOLUTION Drops |
3 |
Preferred Brand |
$40.00 | $120.00 | S |
RIBAVIRIN 200 MG CAPSULE |
2* |
Generic |
$0.00 | $0.00 | None |
RIBAVIRIN 200 MG TABLET [Ribasphere] |
2* |
Generic |
$0.00 | $0.00 | None |
RIDAURA 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
2* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 150 MG CAPSULE |
2* |
Generic |
$0.00 | $0.00 | None |
RIFAMPIN 300 MG CAPSULE |
2* |
Generic |
$0.00 | $0.00 | None |
RIFAMPIN IV 600 MG VIAL [Rifadin] |
2* |
Generic |
$0.00 | $0.00 | None |
RILUZOLE 50 MG TABLET [Rilutek] |
2* |
Generic |
$0.00 | $0.00 | None |
RINVOQ ER 15 MG TABLET ER 24H |
5 |
Specialty Tier |
25% | N/A | P |
RISEDRONATE SODIUM 150 MG TABLET [Actonel] |
2* |
Generic |
$0.00 | $0.00 | Q:1 /28Days |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2* |
Generic |
$0.00 | $0.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2* |
Generic |
$0.00 | $0.00 | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2* |
Generic |
$0.00 | $0.00 | Q:4 /28Days |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISEDRONATE SODIUM DR 35 MG TABLET DR [Atelvia] |
2* |
Generic |
$0.00 | $0.00 | Q:4 /28Days |
RISPERDAL 0.5 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P Q:60 /30Days |
RISPERDAL 1 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P Q:60 /30Days |
RISPERDAL 1MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P Q:480 /30Days |
RISPERDAL 2 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P Q:60 /30Days |
RISPERDAL 3 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P Q:60 /30Days |
RISPERDAL 4 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 0.25 MG TABLET [Risperdal] |
1* |
Preferred Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 0.5 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 0.5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 1 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 1 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 1 MG/ML SOLUTION |
2* |
Generic |
$0.00 | $0.00 | P Q:480 /30Days |
RISPERIDONE 2 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 2 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 3 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 3 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P Q:60 /30Days |
RISPERIDONE 4 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2* |
Generic |
$0.00 | $0.00 | P Q:120 /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 |
$0.00 | $0.00 | P Q:120 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P Q:60 /30Days |
RITALIN 10MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:90 /30Days |
RITALIN 20MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:90 /30Days |
RITALIN 5MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:90 /30Days |
RITONAVIR 100 MG TABLET [Norvir] |
2* |
Generic |
$0.00 | $0.00 | Q:360 /30Days |
RIVASTIGMINE 1.5 MG CAPSULE [Exelon] |
2* |
Generic |
$0.00 | $0.00 | None |
RIVASTIGMINE 13.3 MG/24HR PTCH |
2* |
Generic |
$0.00 | $0.00 | None |
RIVASTIGMINE 3 MG CAPSULE [Exelon] |
2* |
Generic |
$0.00 | $0.00 | None |
RIVASTIGMINE 4.5 MG CAPSULE [Exelon] |
2* |
Generic |
$0.00 | $0.00 | None |
RIVASTIGMINE 4.6 MG/24HR PATCH |
2* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 6 MG CAPSULE [Exelon] |
2* |
Generic |
$0.00 | $0.00 | None |
RIVASTIGMINE 9.5 MG/24HR PATCH |
2* |
Generic |
$0.00 | $0.00 | None |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
2* |
Generic |
$0.00 | $0.00 | Q:18 /30Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
2* |
Generic |
$0.00 | $0.00 | Q:18 /30Days |
RIZATRIPTAN 5 MG ODT TABLET RAPDIS [Maxalt-MLT] |
2* |
Generic |
$0.00 | $0.00 | Q:18 /30Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
2* |
Generic |
$0.00 | $0.00 | Q:18 /30Days |
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
ROCKLATAN 0.02%-0.005% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $120.00 | S |
ROPINIROLE HCL 0.25 MG TABLET |
2* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL 0.5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL 1 MG TABLET [Requip] |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL 2 MG TABLET [Requip] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL 3 MG TABLET |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL 4 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL 5 MG TABLET |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL ER 12 MG TABLET ER 24H [Requip XL] |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL ER 2 MG TABLET ER 24H [Requip XL] |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL ER 4 MG TABLET ER 24H [Requip XL] |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL ER 6 MG TABLET ER 24H [Requip XL] |
2* |
Generic |
$0.00 | $0.00 | None |
ROPINIROLE HCL ER 8 MG TABLET ER 24H [Requip XL] |
2* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
ROSUVASTATIN CALCIUM 40 MG TABLET [Crestor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
ROTARIX VACCINE SUSPENSION |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ROTATEQ VACCINE SOLUTION |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Rowasa Rectal 4 G 60 ml Kit 28X60 |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
ROWEEPRA 500 MG TABLET |
2* |
Generic |
$0.00 | $0.00 | None |
ROXICODONE 15 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:180 /30Days |
ROXICODONE 30 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:180 /30Days |
ROXICODONE 5 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROZEREM 8 MG TABLET |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days |
ROZLYTREK 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:150 /30Days |
ROZLYTREK 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
RUBRACA 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [Banzel] |
5 |
Specialty Tier |
25% | N/A | None |
RUKOBIA ER 600 MG TABLETLET ER 12H |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
RYBELSUS 14 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | S Q:30 /30Days |
RYBELSUS 3 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | S Q:30 /30Days |
RYBELSUS 7 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
RYTARY ER 23.75 MG-95 MG CAP |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RYTARY ER 36.25 MG-145 MG CAP |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RYTARY ER 48.75 MG-195 MG CAP |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RYTARY ER 61.25 MG-245 MG CAP |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | None |
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
25% | N/A | None |
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
25% | N/A | None |