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

2009 Medicare Part D Plan Formulary Information
UPMC for Life Prescription Drug Plan (S3389-005-0) Benefit Details
The UPMC for Life Prescription Drug Plan (S3389-005-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 6 which includes: PA WV
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	$32.00	$80.00	None
RAMIPRIL 1.25MG CAPSULE	1	Generic	$5.00	$12.50	None
RAMIPRIL 10MG CAPSULE	1	Generic	$5.00	$12.50	None
RAMIPRIL 2.5MG CAPSULE	1	Generic	$5.00	$12.50	None
RAMIPRIL 5MG CAPSULE	1	Generic	$5.00	$12.50	None
RANEXA 1000MG TABLET SR 12HR	2	Preferred Brand	$32.00	$80.00	Q:62 /31Days
RANEXA 500MG TABLET	2	Preferred Brand	$32.00	$80.00	Q:124 /31Days
RANICLOR 250MG TABLET CHEWABLE	3	Non-Preferred Brand	$80.00	$200.00	None
RANICLOR 375MG TABLET CHEWABLE	3	Non-Preferred Brand	$80.00	$200.00	None
RANITIDINE 1000MG/40ML VIAL	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE 150MG CAPSULE	1	Generic	$5.00	$12.50	None
RANITIDINE HCL 15MG/ML SYRUP	1	Generic	$5.00	$12.50	None
RANITIDINE HCL 25MG/ML VIAL	1	Generic	$5.00	$12.50	None
RANITIDINE HCL 25MG/ML VIAL	1	Generic	$5.00	$12.50	None
RANITIDINE HCL 300MG CAPSULE (30 CT)	1	Generic	$5.00	$12.50	None
RANITIDINE TABLET 300MG (100 CT)	1	Generic	$5.00	$12.50	None
RANITIDINE TABLET USP 150MG (500 CT)	1	Generic	$5.00	$12.50	None
RAPAFLO CAPSULES 4MG 30 BOT	3	Non-Preferred Brand	$80.00	$200.00	None
RAPAFLO CAPSULES 8MG 90 BOT	3	Non-Preferred Brand	$80.00	$200.00	None
RAPAMUNE 1MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	P
RAPAMUNE 1MG/ML ORAL TUBEX	3	Non-Preferred Brand	$80.00	$200.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RAPAMUNE 2MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	P
RAZADYNE 12MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
RAZADYNE 4MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
RAZADYNE 8MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
RAZADYNE ER 16MG CAPSULE	3	Non-Preferred Brand	$80.00	$200.00	None
RAZADYNE ER 24MG CAPSULE	3	Non-Preferred Brand	$80.00	$200.00	None
RAZADYNE ER 8MG CAPSULE	3	Non-Preferred Brand	$80.00	$200.00	None
RAZADYNE SOL 4MG/ML	3	Non-Preferred Brand	$80.00	$200.00	None
REBETOL 200MG CAPSULE	4	Specialty	33%	N/A	Q:186 /31Days
REBETOL 40MG/ML SOLUTION	4	Specialty	33%	N/A	Q:1085 /31Days
REBIF 22MCG/0.5ML SYRINGE	4	Specialty	33%	N/A	Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REBIF 44MCG/0.5ML SYRINGE	4	Specialty	33%	N/A	Q:12 /30Days
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL	4	Specialty	33%	N/A	Q:12 /30Days
RECLIPSEN 0.15-0.03 TABLET	1	Generic	$5.00	$12.50	None
RECOMBIVAX HB 40MCG/ML VIAL	2	Preferred Brand	$32.00	$80.00	None
RECOMBIVAX HB 5MCG/0.5ML VL	2	Preferred Brand	$32.00	$80.00	None
REGONOL AMP 10MG 5ML	3	Non-Preferred Brand	$80.00	$200.00	None
REGRANEX 0.01% GEL	4	Specialty	33%	N/A	None
RELENZA 5MG DISKHALER	2	Preferred Brand	$32.00	$80.00	Q:120 /365Days
RELION 70/30 INJ 100/ML	3	Non-Preferred Brand	$80.00	$200.00	None
RELION 70/30 INJ INNOLET 2 0.33%	3	Non-Preferred Brand	$80.00	$200.00	None
RELION N INJ 100/ML	3	Non-Preferred Brand	$80.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RELION N INJ INNOLET 3 0.50%	3	Non-Preferred Brand	$80.00	$200.00	None
RELION R INJ 100/ML	3	Non-Preferred Brand	$80.00	$200.00	None
RELISTOR KIT	3	Non-Preferred Brand	$80.00	$200.00	P
RELISTOR SOLUTION	3	Non-Preferred Brand	$80.00	$200.00	P
REMICADE 100MG VIAL	4	Specialty	33%	N/A	P
REMODULIN 10MG/ML VIAL	4	Specialty	33%	N/A	P
REMODULIN 1MG/ML VIAL	4	Specialty	33%	N/A	P
REMODULIN 2.5MG/ML VIAL	4	Specialty	33%	N/A	P
REMODULIN 5MG/ML VIAL	4	Specialty	33%	N/A	P
RENAGEL 400MG TABLET	2	Preferred Brand	$32.00	$80.00	None
RENAGEL 800MG TABLET	2	Preferred Brand	$32.00	$80.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RENAMIN 6.5% IV SOLUTION	3	Non-Preferred Brand	$80.00	$200.00	None
RENVELA 800MG TABLET	2	Preferred Brand	$32.00	$80.00	None
RESCRIPTOR 100MG TABLET	2	Preferred Brand	$32.00	$80.00	None
RESCRIPTOR 200MG TABLET	2	Preferred Brand	$32.00	$80.00	None
RESERPINE 0.1MG TABLET	1	Generic	$5.00	$12.50	None
RESERPINE 0.25MG TABLET	1	Generic	$5.00	$12.50	None
RESTASIS 0.05% EYE EMULSION	3	Non-Preferred Brand	$80.00	$200.00	None
RETROVIR IV INFUSION VIAL	3	Non-Preferred Brand	$80.00	$200.00	None
REVATIO 20MG TABLET	4	Specialty	33%	N/A	P
REVLIMID 10MG CAPSULE (100 CT)	4	Specialty	33%	N/A	P
REVLIMID 15MG CAPSULE 21 BOT	4	Specialty	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REVLIMID 25MG CAPSULE (100 CT)	4	Specialty	33%	N/A	P
REVLIMID 5MG CAPSULE	4	Specialty	33%	N/A	P
REYATAZ 100MG CAPSULE	4	Specialty	33%	N/A	None
REYATAZ 150MG CAPSULE	4	Specialty	33%	N/A	None
REYATAZ 200MG CAPSULE	4	Specialty	33%	N/A	None
REYATAZ 300MG CAPSULE	4	Specialty	33%	N/A	None
RIBAPAK 400-400MG TABLET DOSE PACK	4	Specialty	33%	N/A	Q:93 /31Days
RIBAPAK 600-400MG TABLET DOSE PACK	4	Specialty	33%	N/A	Q:62 /31Days
RIBAPAK 600-600MG TABLET DOSE PACK	4	Specialty	33%	N/A	Q:62 /31Days
RIBASPHERE 200MG CAPSULE	4	Specialty	33%	N/A	Q:186 /31Days
RIBASPHERE 200MG TABLET	4	Specialty	33%	N/A	Q:186 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIBASPHERE 400MG TABLET	4	Specialty	33%	N/A	Q:93 /31Days
RIBASPHERE 600MG TABLET	4	Specialty	33%	N/A	Q:62 /31Days
RIBATAB 400MG TABLET	4	Specialty	33%	N/A	Q:93 /31Days
RIBATAB 600MG TABLET	4	Specialty	33%	N/A	Q:62 /31Days
RIBAVIRIN 200MG CAPSULE	1	Generic	$5.00	$12.50	Q:186 /31Days
RIBAVIRIN 200MG TABLET 168 BOT	1	Generic	$5.00	$12.50	Q:186 /31Days
RIDAURA 3MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
RIFAMATE CAPSULE	3	Non-Preferred Brand	$80.00	$200.00	None
RIFAMPIN 150MG CAPSULE (30 CT)	1	Generic	$5.00	$12.50	None
RIFAMPIN 300MG CAPSULE	1	Generic	$5.00	$12.50	None
RIFAMPIN 600MG VIAL	4	Specialty	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIFATER TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
RILUTEK 50MG TABLET	4	Specialty	33%	N/A	None
RIMANTADINE 100MG TABLET	1	Generic	$5.00	$12.50	None
RINGERS INJECTION 1000ML BAG	1	Generic	$5.00	$12.50	None
RINGERS IRRIGATION 860-30 12X1000ML BAG	1	Generic	$5.00	$12.50	None
RIOMET 500MG/5ML SOLUTION ORAL	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL 1MG M-TAB	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL 1MG/ML SOLUTION	2	Preferred Brand	$32.00	$80.00	None
RISPERDAL 2MG M-TAB	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL 3MG M-TAB	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL 4MG M-TAB	3	Non-Preferred Brand	$80.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERDAL CONSTA 25MG SYR	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL CONSTA 37.5MG SYR	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL CONSTA 50MG SYR	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERDAL M TABLET 0.5MG	3	Non-Preferred Brand	$80.00	$200.00	None
RISPERIDONE TABLET	1	Generic	$5.00	$12.50	None
RISPERIDONE TABLET 1 MG	1	Generic	$5.00	$12.50	None
RISPERIDONE TABLET 2 MG	1	Generic	$5.00	$12.50	None
RISPERIDONE TABLET 3 MG	1	Generic	$5.00	$12.50	None
RISPERIDONE TABLET 4 MG	1	Generic	$5.00	$12.50	None
RISPERIODONE TABLET	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RITUXAN 10MG/ML VIAL	4	Specialty	33%	N/A	P
ROBAXIN 100MG/ML VIAL	3	Non-Preferred Brand	$80.00	$200.00	None
ROCEPHIN/DEX INJ 1GM	3	Non-Preferred Brand	$80.00	$200.00	None
ROMYCIN 5MG/G OINTMENT	1	Generic	$5.00	$12.50	None
ROPINIROLE HCL TABLET	1	Generic	$5.00	$12.50	None
ROPINIROLE HCL TABLET 1 MG	1	Generic	$5.00	$12.50	None
ROPINIROLE HCL TABLET 2 MG	1	Generic	$5.00	$12.50	None
ROPINIROLE HCL TABLET 3 MG	1	Generic	$5.00	$12.50	None
ROPINIROLE HCL TABLET 4 MG	1	Generic	$5.00	$12.50	None
ROPINIROLE HCL TABLET 5 MG	1	Generic	$5.00	$12.50	None
ROPINIROLE HYDROCLORIDE TABLET	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROTATEQ VACCINE	2	Preferred Brand	$32.00	$80.00	None
ROXICET 5-325/5ML SOLUTION ORAL	3	Non-Preferred Brand	$80.00	$200.00	None
ROXICET 5/325 TABLET	1	Generic	$5.00	$12.50	None
ROXICET 5/500 CAPLET	3	Non-Preferred Brand	$80.00	$200.00	None
ROXICODONE 15MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
ROXICODONE 30MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
ROXILOX 500-5MG (100 CT)	1	Generic	$5.00	$12.50	None
RYTHMOL SR 225MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
RYTHMOL SR 325MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None
RYTHMOL SR 425MG CAPSULE	2	Preferred Brand	$32.00	$80.00	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D UPMC for Life Prescription Drug Plan 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.