2021 Medicare Part D Plan Formulary Information |
Freedom Blue PPO Deluxe (PPO) (H3916-005-0)
Benefit Details
|
The Freedom Blue PPO Deluxe (PPO) (H3916-005-0) Formulary Drugs Starting with the Letter R in Adams County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $289.00 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 |
$45.00 | $115.00 | P |
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex] |
2 |
Generic |
$13.00 | $27.00 | Q:62 /31Days |
RALOXIFENE HCL 60 MG TABLET [Evista] |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
RAMELTEON 8 MG TABLET [Rozerem] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:31 /31Days |
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 |
RANOLAZINE ER 1,000 MG TABLET 12H [Ranexa] |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:62 /31Days |
RANOLAZINE ER 500 MG TABLET 12H [Ranexa] |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RAPAMUNE 0.5MG TABLETS |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RAPAMUNE 1MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
RAPAMUNE 1MG/ML ORAL TUBEX |
5 |
Specialty Tier |
33% | N/A | P |
RAPAMUNE 2MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
RASAGILINE MESYLATE 0.5 MG TABLET [Azilect] |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
RASAGILINE MESYLATE 1 MG TABLET [Azilect] |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
RASUVO 10 MG/0.2 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 12.5 MG/0.25 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 15 MG/0.3 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 17.5 MG/0.35 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 20 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RASUVO 22.5 MG/0.45 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 25 MG/0.5 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 30 MG/0.6 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RASUVO 7.5 MG/0.15 ML AUTOINJ |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
33% | N/A | P |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF REBIDOSE TITRATION PACK |
5 |
Specialty Tier |
33% | N/A | Q:4 /365Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
33% | N/A | Q:8 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RECLIPSEN 28 DAY TABLET [Solia] |
2 |
Generic |
$13.00 | $27.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RECOMBIVAX HB 10 MCG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
REDITREX 10 MG/0.4 ML SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REDITREX 12.5 MG/0.5 ML SYRING SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REDITREX 15 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REDITREX 17.5 MG/0.7 ML SYRING SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REDITREX 20 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REDITREX 22.5 MG/0.9 ML SYRING SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REDITREX 25 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REDITREX 7.5 MG/0.3 ML SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
33% | N/A | P |
RELENZA 5MG DISKHALER |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
RELISTOR 12 MG/0.6 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:19 /31Days |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:19 /31Days |
RELISTOR 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:93 /31Days |
RELISTOR 8 MG/0.4 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:12 /31Days |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:124 /31Days |
REPAGLINIDE 1 MG TABLET [Prandin] |
2 |
Generic |
$13.00 | $27.00 | Q:124 /31Days |
REPAGLINIDE 2 MG TABLET [Prandin] |
2 |
Generic |
$13.00 | $27.00 | Q:248 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REPATHA 140 MG/ML SURECLICK PEN INJCTR |
3 |
Preferred Brand |
$45.00 | $115.00 | P Q:3 /28Days |
REPATHA 140 MG/ML SYRINGE |
3 |
Preferred Brand |
$45.00 | $115.00 | P Q:3 /28Days |
REPATHA 420 MG/3.5ML PUSHTRONX WEAR INJCT |
3 |
Preferred Brand |
$45.00 | $115.00 | P Q:7 /28Days |
RESTASIS 0.05% EYE EMULSION |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:60 /30Days |
RETACRIT 10,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RETACRIT 2,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RETACRIT 20,000 UNIT/2 ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RETACRIT 20,000 UNIT/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
RETACRIT 3,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RETACRIT 4,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$45.00 | $115.00 | P |
RETACRIT 40,000 UNIT/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETEVMO 40 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:186 /31Days |
RETEVMO 80 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:124 /31Days |
RETIN-A MICRO PUMP 0.06% GEL |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P |
REVATIO 10 MG/ML ORAL SUSP |
5 |
Specialty Tier |
33% | N/A | P Q:224 /31Days |
REVATIO 20MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:93 /31Days |
REVLIMID 10 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 25 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
REVLIMID 5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
REYATAZ 50 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
REYVOW 100 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:8 /28Days |
REYVOW 50 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:4 /28Days |
RIBAVIRIN 200 MG CAPSULE |
2 |
Generic |
$13.00 | $27.00 | None |
RIBAVIRIN 200 MG TABLET [Ribasphere] |
2 |
Generic |
$13.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIDAURA 3 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
RIFAMPIN 150 MG CAPSULE |
2 |
Generic |
$13.00 | $27.00 | None |
RIFAMPIN 300 MG CAPSULE |
2 |
Generic |
$13.00 | $27.00 | None |
RIFAMPIN IV 600 MG VIAL [Rifadin] |
2 |
Generic |
$13.00 | $27.00 | None |
RILUZOLE 50 MG TABLET [Rilutek] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Generic |
$13.00 | $27.00 | None |
RINVOQ ER 15 MG TABLET ER 24H |
5 |
Specialty Tier |
33% | N/A | P Q:31 /31Days |
RISEDRONATE SODIUM 150 MG TABLET [Actonel] |
2 |
Generic |
$13.00 | $27.00 | None |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
2 |
Generic |
$13.00 | $27.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$13.00 | $27.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$13.00 | $27.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$13.00 | $27.00 | None |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
2 |
Generic |
$13.00 | $27.00 | None |
RISEDRONATE SODIUM DR 35 MG TABLET DR [Atelvia] |
2 |
Generic |
$13.00 | $27.00 | None |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
33% | N/A | Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | N/A | Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:2 /28Days |
RISPERIDONE 0.25 MG TABLET [Risperdal] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:31 /31Days |
RISPERIDONE 0.5 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:31 /31Days |
RISPERIDONE 0.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 1 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:31 /31Days |
RISPERIDONE 1 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:31 /31Days |
RISPERIDONE 1 MG/ML SOLUTION |
2 |
Generic |
$13.00 | $27.00 | Q:496 /31Days |
RISPERIDONE 2 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:31 /31Days |
RISPERIDONE 2 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:31 /31Days |
RISPERIDONE 3 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:93 /31Days |
RISPERIDONE 3 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:93 /31Days |
RISPERIDONE 4 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:124 /31Days |
RISPERIDONE 4 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:124 /31Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:31 /31Days |
RITONAVIR 100 MG TABLET [Norvir] |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 1.5 MG CAPSULE [Exelon] |
2 |
Generic |
$13.00 | $27.00 | None |
RIVASTIGMINE 13.3 MG/24HR PTCH |
2 |
Generic |
$13.00 | $27.00 | Q:30 /30Days |
RIVASTIGMINE 3 MG CAPSULE [Exelon] |
2 |
Generic |
$13.00 | $27.00 | None |
RIVASTIGMINE 4.5 MG CAPSULE [Exelon] |
2 |
Generic |
$13.00 | $27.00 | None |
RIVASTIGMINE 4.6 MG/24HR PATCH |
2 |
Generic |
$13.00 | $27.00 | Q:30 /30Days |
RIVASTIGMINE 6 MG CAPSULE [Exelon] |
2 |
Generic |
$13.00 | $27.00 | None |
RIVASTIGMINE 9.5 MG/24HR PATCH |
2 |
Generic |
$13.00 | $27.00 | Q:30 /30Days |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
2 |
Generic |
$13.00 | $27.00 | Q:12 /28Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
2 |
Generic |
$13.00 | $27.00 | Q:12 /28Days |
RIZATRIPTAN 5 MG ODT TABLET RAPDIS [Maxalt-MLT] |
2 |
Generic |
$13.00 | $27.00 | Q:24 /28Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
2 |
Generic |
$13.00 | $27.00 | Q:24 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL 0.25 MG TABLET |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL 0.5 MG TABLET |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL 1 MG TABLET [Requip] |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL 2 MG TABLET [Requip] |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL 3 MG TABLET |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL 4 MG TABLET |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL 5 MG TABLET |
2 |
Generic |
$13.00 | $27.00 | None |
ROPINIROLE HCL ER 12 MG TABLET ER 24H [Requip XL] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
ROPINIROLE HCL ER 2 MG TABLET ER 24H [Requip XL] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
ROPINIROLE HCL ER 4 MG TABLET ER 24H [Requip XL] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
ROPINIROLE HCL ER 6 MG TABLET ER 24H [Requip XL] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL ER 8 MG TABLET ER 24H [Requip XL] |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None |
ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor] |
2 |
Generic |
$13.00 | $27.00 | None |
ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor] |
2 |
Generic |
$13.00 | $27.00 | None |
ROSUVASTATIN CALCIUM 40 MG TABLET [Crestor] |
2 |
Generic |
$13.00 | $27.00 | None |
ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor] |
2 |
Generic |
$13.00 | $27.00 | None |
ROTARIX VACCINE SUSPENSION |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
ROTATEQ VACCINE SOLUTION |
3 |
Preferred Brand |
$45.00 | $115.00 | None |
ROWEEPRA 500 MG TABLET |
2 |
Generic |
$13.00 | $27.00 | None |
ROZLYTREK 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:155 /31Days |
ROZLYTREK 200 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:93 /31Days |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:124 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RUBRACA 250 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:124 /31Days |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:124 /31Days |
RUCONEST 2,100 UNIT VIAL |
5 |
Specialty Tier |
33% | N/A | P |
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [Banzel] |
5 |
Specialty Tier |
33% | N/A | P |
RUKOBIA ER 600 MG TABLETLET ER 12H |
5 |
Specialty Tier |
33% | N/A | Q:62 /31Days |
RUZURGI 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:310 /31Days |
RYBELSUS 14 MG TABLET |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:31 /31Days |
RYBELSUS 3 MG TABLET |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:31 /31Days |
RYBELSUS 7 MG TABLET |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:31 /31Days |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:248 /31Days |
RYTARY ER 23.75 MG-95 MG CAP |
3 |
Preferred Brand |
$45.00 | $115.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RYTARY ER 36.25 MG-145 MG CAP |
3 |
Preferred Brand |
$45.00 | $115.00 | S |
RYTARY ER 48.75 MG-195 MG CAP |
3 |
Preferred Brand |
$45.00 | $115.00 | S |
RYTARY ER 61.25 MG-245 MG CAP |
3 |
Preferred Brand |
$45.00 | $115.00 | S |