Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
Advantage Star Plan by RxAmerica (S5644-080-0) Benefit Details
The Advantage Star Plan by RxAmerica (S5644-080-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter R Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter R Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RABAVERT RABIES VACCINE KIT 2.5 IU/ML	2	Preferred Brand	25%	30%	None
RAMIPRIL 1.25MG CAPSULE	1	Preferred Generic	$5.50	$0.00	None
RAMIPRIL 10MG CAPSULE	1	Preferred Generic	$5.50	$0.00	None
RAMIPRIL 2.5MG CAPSULE	1	Preferred Generic	$5.50	$0.00	None
RAMIPRIL 5MG CAPSULE	1	Preferred Generic	$5.50	$0.00	None
RANEXA 1000MG TABLET SR 12HR	2	Preferred Brand	25%	30%	P
RANEXA 500MG TABLET	2	Preferred Brand	25%	30%	P
RANITIDINE 150MG CAPSULE	1	Preferred Generic	$5.50	$0.00	None
RANITIDINE HCL 15MG/ML SYRUP	1	Preferred Generic	$5.50	$0.00	None
RANITIDINE HCL 25MG/ML VIAL	1	Preferred Generic	$5.50	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE HCL 25MG/ML VIAL	1	Preferred Generic	$5.50	$0.00	None
RANITIDINE HCL 300MG CAPSULE (30 CT)	1	Preferred Generic	$5.50	$0.00	None
RANITIDINE TABLET 300MG (100 CT)	1	Preferred Generic	$5.50	$0.00	None
RANITIDINE TABLET USP 150MG (500 CT)	1	Preferred Generic	$5.50	$0.00	None
RAPAMUNE 1MG TABLET	2	Preferred Brand	25%	30%	P
RAPAMUNE 1MG/ML ORAL TUBEX	2	Preferred Brand	25%	30%	P
RAPAMUNE 2MG TABLET	2	Preferred Brand	25%	30%	P
REBETOL 40MG/ML SOLUTION	2	Preferred Brand	25%	30%	P
RECLIPSEN 0.15-0.03 TABLET	1	Preferred Generic	$5.50	$0.00	None
RECOMBIVAX HB 40MCG/ML VIAL	2	Preferred Brand	25%	30%	P
RECOMBIVAX HB 5MCG/0.5ML VL	2	Preferred Brand	25%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REGONOL AMP 10MG 5ML	1	Preferred Generic	$5.50	$0.00	None
REGRANEX 0.01% GEL	2	Preferred Brand	25%	30%	P
RELENZA 5MG DISKHALER	2	Preferred Brand	25%	30%	None
RELION 70/30 INJ 100/ML	2	Preferred Brand	25%	30%	None
RELION 70/30 INJ INNOLET 2 0.33%	2	Preferred Brand	25%	30%	None
RELION N INJ 100/ML	2	Preferred Brand	25%	30%	None
RELION N INJ INNOLET 3 0.50%	2	Preferred Brand	25%	30%	None
RELION R INJ 100/ML	2	Preferred Brand	25%	30%	None
RELISTOR KIT	2	Preferred Brand	25%	30%	P
RELISTOR SOLUTION	2	Preferred Brand	25%	30%	P
RELPAX 20MG TABLET	2	Preferred Brand	25%	30%	Q:9 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RELPAX 40MG TABLET 6X2 BLPK	2	Preferred Brand	25%	30%	Q:9 /30Days
REMICADE 100MG VIAL	3	Specialty	25%	N/A	None
RENAGEL 400MG TABLET	2	Preferred Brand	25%	30%	None
RENAGEL 800MG TABLET	2	Preferred Brand	25%	30%	None
RENAMIN 6.5% IV SOLUTION	2	Preferred Brand	25%	30%	P
RENVELA 800MG TABLET	2	Preferred Brand	25%	30%	None
REQUIP 0.25MG TABLET	2	Preferred Brand	25%	30%	None
REQUIP 0.5MG TABLET	2	Preferred Brand	25%	30%	None
REQUIP 1MG TABLET	2	Preferred Brand	25%	30%	None
REQUIP 2MG TABLET	2	Preferred Brand	25%	30%	None
REQUIP 3MG TABLET	2	Preferred Brand	25%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REQUIP 4MG TABLET	2	Preferred Brand	25%	30%	None
REQUIP 5MG TABLET	2	Preferred Brand	25%	30%	None
RESCRIPTOR 100MG TABLET	2	Preferred Brand	25%	30%	None
RESCRIPTOR 200MG TABLET	2	Preferred Brand	25%	30%	None
RESTASIS 0.05% EYE EMULSION	2	Preferred Brand	25%	30%	None
RETROVIR 100MG CAPSULE	2	Preferred Brand	25%	30%	None
RETROVIR IV INFUSION VIAL	2	Preferred Brand	25%	30%	None
REVATIO 20MG TABLET	2	Preferred Brand	25%	30%	P
REVLIMID 10MG CAPSULE (100 CT)	2	Preferred Brand	25%	30%	P
REVLIMID 15MG CAPSULE 21 BOT	2	Preferred Brand	25%	30%	P
REVLIMID 25MG CAPSULE (100 CT)	2	Preferred Brand	25%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REVLIMID 5MG CAPSULE	2	Preferred Brand	25%	30%	P
REYATAZ 100MG CAPSULE	2	Preferred Brand	25%	30%	None
REYATAZ 150MG CAPSULE	2	Preferred Brand	25%	30%	None
REYATAZ 200MG CAPSULE	2	Preferred Brand	25%	30%	None
REYATAZ 300MG CAPSULE	2	Preferred Brand	25%	30%	None
RIBASPHERE 200MG CAPSULE	1	Preferred Generic	$5.50	$0.00	P
RIBASPHERE 200MG TABLET	1	Preferred Generic	$5.50	$0.00	P
RIBAVIRIN 200MG CAPSULE	1	Preferred Generic	$5.50	$0.00	P
RIBAVIRIN 200MG TABLET 168 BOT	1	Preferred Generic	$5.50	$0.00	P
RIDAURA 3MG CAPSULE	2	Preferred Brand	25%	30%	None
RIFAMPIN 150MG CAPSULE (30 CT)	1	Preferred Generic	$5.50	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIFAMPIN 300MG CAPSULE	1	Preferred Generic	$5.50	$0.00	None
RIFAMPIN 600MG VIAL	1	Preferred Generic	$5.50	$0.00	None
RILUTEK 50MG TABLET	2	Preferred Brand	25%	30%	None
RIMANTADINE 100MG TABLET	1	Preferred Generic	$5.50	$0.00	None
RIOMET 500MG/5ML SOLUTION ORAL	2	Preferred Brand	25%	30%	None
RISPERDAL 0.25MG TABLET	4	Non-Preferred	45%	45%	P
RISPERDAL 0.5MG TABLET	4	Non-Preferred	45%	45%	P
RISPERDAL 1MG M-TAB	4	Non-Preferred	45%	45%	P
RISPERDAL 1MG TABLET	4	Non-Preferred	45%	45%	P
RISPERDAL 1MG/ML SOLUTION	4	Non-Preferred	45%	45%	P
RISPERDAL 2MG M-TAB	4	Non-Preferred	45%	45%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERDAL 2MG TABLET	4	Non-Preferred	45%	45%	P
RISPERDAL 3MG TABLET	4	Non-Preferred	45%	45%	None
RISPERDAL 4MG TABLET	4	Non-Preferred	45%	45%	P
RISPERDAL CONSTA 25MG SYR	4	Non-Preferred	45%	45%	P
RISPERDAL CONSTA 37.5MG SYR	4	Non-Preferred	45%	45%	P
RISPERDAL CONSTA 50MG SYR	4	Non-Preferred	45%	45%	P
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	4	Non-Preferred	45%	45%	P
RISPERDAL M TABLET 0.5MG	4	Non-Preferred	45%	45%	P
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR	1	Preferred Generic	$5.50	$0.00	None
RISPERIDONE TABLET	1	Preferred Generic	$5.50	$0.00	None
RISPERIDONE TABLET 1 MG	1	Preferred Generic	$5.50	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE TABLET 2 MG	1	Preferred Generic	$5.50	$0.00	None
RISPERIDONE TABLET 3 MG	1	Preferred Generic	$5.50	$0.00	None
RISPERIDONE TABLET 4 MG	1	Preferred Generic	$5.50	$0.00	None
RISPERIODONE TABLET	1	Preferred Generic	$5.50	$0.00	None
RITUXAN 10MG/ML VIAL	3	Specialty	25%	N/A	None
ROBAXIN 100MG/ML VIAL	2	Preferred Brand	25%	30%	None
ROBINUL 0.2MG/ML VIAL	2	Preferred Brand	25%	30%	None
ROBINUL 1MG TABLET	2	Preferred Brand	25%	30%	None
ROBINUL FORTE 2MG TABLET	2	Preferred Brand	25%	30%	None
ROMYCIN 5MG/G OINTMENT	1	Preferred Generic	$5.50	$0.00	None
ROPINIROLE HCL TABLET	1	Preferred Generic	$5.50	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROPINIROLE HCL TABLET 1 MG	1	Preferred Generic	$5.50	$0.00	None
ROPINIROLE HCL TABLET 2 MG	1	Preferred Generic	$5.50	$0.00	None
ROPINIROLE HCL TABLET 3 MG	1	Preferred Generic	$5.50	$0.00	None
ROPINIROLE HCL TABLET 4 MG	1	Preferred Generic	$5.50	$0.00	None
ROPINIROLE HCL TABLET 5 MG	1	Preferred Generic	$5.50	$0.00	None
ROPINIROLE HYDROCLORIDE TABLET	1	Preferred Generic	$5.50	$0.00	None
ROTATEQ VACCINE	2	Preferred Brand	25%	30%	P
ROXICET 5/325 TABLET	1	Preferred Generic	$5.50	$0.00	None
ROXILOX 500-5MG (100 CT)	1	Preferred Generic	$5.50	$0.00	None
RYTHMOL SR 225MG CAPSULE	2	Preferred Brand	25%	30%	None
RYTHMOL SR 325MG CAPSULE	2	Preferred Brand	25%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RYTHMOL SR 425MG CAPSULE	2	Preferred Brand	25%	30%	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Advantage Star Plan by RxAmerica Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.