Drug List - R

R
Drug Name Tier Restrictions
RABAVART INJ 3
RABEPRAZOLE NC
RAGWITEK SUB 3
RALOXIFENE 1
RAMIPRIL 1
RANEXA 3 Prior authorization
RANITIDINE 15MG/ML ORAL SOLUTION (AGE RESTRICTION 4-12 YEARS OLD) 1
RANITIDINE HCL NC
RAPAFLO CAP 3 Prior authorization
RAPAMUNE $0
RASUVO 3 Prior authorization, Step therapy
RAZADYNE 3 Prior authorization
RE-SA 2 Quantity limit
REBIF 3 Prior authorization, Step therapy
RECLAST $0
RECLIPSEN 1*
RELENZA DISKHALER 2
RELPAX 3 Quantity limit, Step therapy
REMERON 3 Prior authorization
REMINYL 2
RENA-VITE 1
RENAGEL 2
RENAL CAP SOFTGEL 3 Prior authorization
RENAX 2
RENOVA NC Quantity limit
RENVELA 2
REPAGLINIDE 1
REPATHA 3 Prior authorization
REPRONEX INJ 75IU UD 3
REQUIP XL 3
RESERPINE 1
RESTASIS EMU 3
RESTORIL 3 Prior authorization
RETIN-A 3 Quantity limit
RETIN-A MICRO 3 Prior authorization, Quantity limit, Step therapy
RETROVIR 3 Prior authorization
REVATIO 3 Quantity limit
REVLIMID CAP 3 Prior authorization
REXULTI TAB 3 Prior authorization
REYATAZ 2
RHINOCORT AQUA NC
RIBAPAK TAB 800/DAY 2
RIBAVIRIN TAB 200MG 1
RIFADIN CAP 2
RIFAMPIN CAP 150MG 1
RILUTEK 3 Prior authorization
RILUZOLE 1
RIMANTADINE HCL 1
RIMSO-50 3
RISEDRONATE TAB 1
RISPERDAL 3
RISPERDAL CONSTA INJ 3 Prior authorization
RISPERDAL M-TAB 3 Prior authorization
RISPERIDONE 1
RITALIN 3 Prior authorization
RITALIN LA 3 Prior authorization, Step therapy
RIVASTIGMINE 1
RIZATRIPTAN 1 Quantity limit
RIZATRIPTAN-MLT 1 Quantity limit
ROPINIROLE EXTENDED RELEASE 1
ROPINIROLE HCL 1
ROSAC 3 Quantity limit
ROSADERM EMU CLEANSER 1 Quantity limit
ROSANIL CLEANSER EMU 3 Quantity limit, Step therapy
ROSIGLITAZONE 1
ROSIGLITAZONE/GLIMEPIRIDE 1
ROSULA 3 Prior authorization, Quantity limit, Step therapy
ROSUVASTATIN 1
ROXICET 1
ROXICODONE 1
ROZEREM 3 Prior authorization, Quantity limit, Step therapy
RYTARY CAP 3
RYTHMOL SR 3 Prior authorization