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Health Net Orange Option 2 (PDP) (S5678-035-0)
Tier 1 (1454)
Tier 2 (642)
Tier 3 (1805)
Tier 4 (687)
Tier 5 (288)
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2010 Medicare Part D Plan Formulary Information
Health Net Orange Option 2 (PDP) (S5678-035-0)
Benefit Details  
The Health Net Orange Option 2 (PDP) (S5678-035-0)
Formulary Drugs Starting with the Letter R

in CMS PDP Region 15 which includes: IN KY
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
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL   4 Tier 4 Injectable 33%N/AP
RAMIPRIL 1.25MG CAPSULE   1 Tier 1 Preferred Generic $5.00$10.00Q:2
/1Days
RAMIPRIL 10MG CAPSULE   1 Tier 1 Preferred Generic $5.00$10.00Q:2
/1Days
RAMIPRIL 2.5MG CAPSULE   1 Tier 1 Preferred Generic $5.00$10.00Q:2
/1Days
RAMIPRIL 5MG CAPSULE   1 Tier 1 Preferred Generic $5.00$10.00Q:2
/1Days
RANEXA 1000MG TABLET SR 12HR   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RANEXA 500MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RANICLOR 250MG TABLET CHEWABLE   3 Tier 3 Non-Preferred $95.00$238.00None
RANICLOR 375MG TABLET CHEWABLE   3 Tier 3 Non-Preferred $95.00$238.00None
RANITIDINE 150MG CAPSULE   1 Tier 1 Preferred Generic $5.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RANITIDINE HCL 15MG/ML SYRUP   1 Tier 1 Preferred Generic $5.00$10.00None
RANITIDINE HCL 25MG/ML VIAL   4 Tier 4 Injectable 33%N/ANone
RANITIDINE HCL 300MG CAPSULE (30 CT)   1 Tier 1 Preferred Generic $5.00$10.00None
RANITIDINE TABLET 300MG (100 CT)   1 Tier 1 Preferred Generic $5.00$10.00None
RANITIDINE TABLET USP 150MG (500 CT)   1 Tier 1 Preferred Generic $5.00$10.00None
RAPAFLO CAPSULES 4MG 30 BOT   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RAPAFLO CAPSULES 8MG 90 BOT   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RAPAMUNE 1MG TABLET   2 Tier 2 Preferred Brand $35.00$70.00P
RAPAMUNE 1MG/ML ORAL TUBEX   2 Tier 2 Preferred Brand $35.00$70.00P
RAPAMUNE 2MG TABLET   2 Tier 2 Preferred Brand $35.00$70.00P
RAZADYNE 12MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RAZADYNE 4MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RAZADYNE 8MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RAZADYNE ER 16MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RAZADYNE ER 24MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RAZADYNE ER 8MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RAZADYNE SOL 4MG/ML   3 Tier 3 Non-Preferred $95.00$238.00Q:8
/1Days
REBETOL 200MG CAPSULE 84 EA   5 Tier 5 Specialty 33%N/AP
REBETOL 40MG/ML SOLUTION   2 Tier 2 Preferred Brand $35.00$70.00P
REBIF 22MCG/0.5ML SYRINGE   5 Tier 5 Specialty 33%N/AP
REBIF 44MCG/0.5ML SYRINGE   5 Tier 5 Specialty 33%N/AP
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL   5 Tier 5 Specialty 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RECLIPSEN 0.15-0.03 TABLET   1 Tier 1 Preferred Generic $5.00$10.00Q:1
/1Days
RECOMBIVAX HB 40MCG/ML VIAL   4 Tier 4 Injectable 33%N/AP
REGLAN 10MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REGLAN 5MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REGLAN 5MG/ML VIAL   4 Tier 4 Injectable 33%N/ANone
REGONOL AMP 10MG 5ML   4 Tier 4 Injectable 33%N/ANone
REGRANEX 0.01% GEL   5 Tier 5 Specialty 33%N/AP
RELENZA 5MG DISKHALER   3 Tier 3 Non-Preferred $95.00$238.00Q:20
/5Days
RELION 70/30 INJ 100/ML   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RELION N INJ 100/ML   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RELION R INJ 100/ML   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RELISTOR SOLUTION   4 Tier 4 Injectable 33%N/AP
RELPAX 20MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RELPAX 40MG TABLET 6X2 BLPK   3 Tier 3 Non-Preferred $95.00$238.00None
REMERON 15MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REMERON 30MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REMERON 45MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN   3 Tier 3 Non-Preferred $95.00$238.00None
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN   3 Tier 3 Non-Preferred $95.00$238.00None
REMERON SLTABLET 45MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REMICADE 100MG VIAL   5 Tier 5 Specialty 33%N/AP
REMODULIN 10MG/ML VIAL   5 Tier 5 Specialty 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REMODULIN 1MG/ML VIAL   5 Tier 5 Specialty 33%N/ANone
REMODULIN 2.5MG/ML VIAL   5 Tier 5 Specialty 33%N/ANone
REMODULIN 5MG/ML VIAL   5 Tier 5 Specialty 33%N/ANone
RENAMIN 6.5% IV SOLUTION   4 Tier 4 Injectable 33%N/AP
RENVELA 800MG TABLET   2 Tier 2 Preferred Brand $35.00$70.00None
REPREXAIN 5-200 MG TABLET 100 EA   3 Tier 3 Non-Preferred $95.00$238.00None
REPREXAIN TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REPREXAIN TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP 0.25MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP 0.5MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP 1MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REQUIP 2MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP 3MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP 4MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP 5MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP XL ROPINIROLE HCL 2MG   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP XL ROPINIROLE HCL 4MG   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP XL ROPINIROLE HCL 8MG   3 Tier 3 Non-Preferred $95.00$238.00None
REQUIP XL TABLET 12 MG   3 Tier 3 Non-Preferred $95.00$238.00None
RESCRIPTOR 100MG TABLET   2 Tier 2 Preferred Brand $35.00$70.00None
RESCRIPTOR 200MG TABLET   2 Tier 2 Preferred Brand $35.00$70.00None
RESERPINE 0.1MG TABLET   1 Tier 1 Preferred Generic $5.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RESERPINE 0.25MG TABLET   1 Tier 1 Preferred Generic $5.00$10.00None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU   3 Tier 3 Non-Preferred $95.00$238.00P Q:2
/1Days
RETIN-A 0.01% GEL   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RETIN-A 0.025% CREAM   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RETIN-A 0.025% GEL   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RETIN-A 0.05% CREAM   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RETIN-A 0.1% CREAM   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RETIN-A MICRO 0.04% GEL   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RETIN-A MICRO 0.1% GEL   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RETROVIR 100MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00None
RETROVIR 10MGML SYRUP   3 Tier 3 Non-Preferred $95.00$238.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RETROVIR 300MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RETROVIR IV INFUSION VIAL   4 Tier 4 Injectable 33%N/ANone
REVATIO 20MG TABLET   5 Tier 5 Specialty 33%N/AP
REVIA 50MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
REVLIMID 10MG CAPSULE (100 CT)   5 Tier 5 Specialty 33%N/AP
REVLIMID 15MG CAPSULE 21 BOT   5 Tier 5 Specialty 33%N/AP
REVLIMID 25MG CAPSULE (100 CT)   5 Tier 5 Specialty 33%N/AP
REVLIMID 5MG CAPSULE   5 Tier 5 Specialty 33%N/AP
REYATAZ 100MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
REYATAZ 150MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
REYATAZ 200MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REYATAZ 300MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
RHEUMATREX 2.5MG TABLET DOSE PACK   2 Tier 2 Preferred Brand $35.00$70.00None
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RIBASPHERE 200MG TABLET   1 Tier 1 Preferred Generic $5.00$10.00P
RIBASPHERE CAPSULES 200MG 42 BOT   5 Tier 5 Specialty 33%N/AP
RIBAVIRIN 200MG CAPSULE   5 Tier 5 Specialty 33%N/AP
RIBAVIRIN 200MG TABLET 168 BOT   1 Tier 1 Preferred Generic $5.00$10.00P
RIDAURA 3MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
RIFADIN 150MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00None
RIFADIN 300MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00None
RIFADIN IV 600MG VIAL   4 Tier 4 Injectable 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RIFAMATE CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00None
RIFAMPIN 150MG CAPSULE (30 CT)   1 Tier 1 Preferred Generic $5.00$10.00None
RIFAMPIN 300MG CAPSULE   1 Tier 1 Preferred Generic $5.00$10.00None
RIFAMPIN 600MG VIAL   4 Tier 4 Injectable 33%N/ANone
RIFATER TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RILUTEK 50MG TABLET   5 Tier 5 Specialty 33%N/ANone
RIMANTADINE 100MG TABLET   1 Tier 1 Preferred Generic $5.00$10.00None
RINGERS INJECTION 1000ML BAG   4 Tier 4 Injectable 33%N/ANone
RINGERS IRRIGATION 860-30 12X1000ML BAG   1 Tier 1 Preferred Generic $5.00$10.00None
RIOMET 500MG/5ML SOLUTION ORAL   2 Tier 2 Preferred Brand $35.00$70.00None
RISPERDAL 0.25MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RISPERDAL 0.5MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:6
/1Days
RISPERDAL 1MG M-TAB   3 Tier 3 Non-Preferred $95.00$238.00Q:6
/1Days
RISPERDAL 1MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:6
/1Days
RISPERDAL 1MG/ML SOLUTION   3 Tier 3 Non-Preferred $95.00$238.00Q:16
/1Days
RISPERDAL 2MG M-TAB   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RISPERDAL 2MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RISPERDAL 3MG M-TAB   3 Tier 3 Non-Preferred $95.00$238.00Q:5
/1Days
RISPERDAL 3MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:5
/1Days
RISPERDAL 4MG M-TAB   3 Tier 3 Non-Preferred $95.00$238.00Q:4
/1Days
RISPERDAL 4MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00Q:4
/1Days
RISPERDAL CONSTA 25MG SYR   4 Tier 4 Injectable 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RISPERDAL CONSTA 37.5MG SYR   4 Tier 4 Injectable 33%N/ANone
RISPERDAL CONSTA 50MG SYR   5 Tier 5 Specialty 33%N/ANone
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL   4 Tier 4 Injectable 33%N/ANone
RISPERDAL M TABLET 0.5MG   3 Tier 3 Non-Preferred $95.00$238.00Q:6
/1Days
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR   1 Tier 1 Preferred Generic $5.00$10.00Q:16
/1Days
RISPERIDONE TABLET   1 Tier 1 Preferred Generic $5.00$10.00Q:2
/1Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RISPERIDONE TABLET 1 MG   1 Tier 1 Preferred Generic $5.00$10.00Q:6
/1Days
RISPERIDONE TABLET 2 MG   1 Tier 1 Preferred Generic $5.00$10.00Q:2
/1Days
RISPERIDONE TABLET 3 MG   1 Tier 1 Preferred Generic $5.00$10.00Q:5
/1Days
RISPERIDONE TABLET 4 MG   1 Tier 1 Preferred Generic $5.00$10.00Q:4
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK   3 Tier 3 Non-Preferred $95.00$238.00Q:5
/1Days
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK   3 Tier 3 Non-Preferred $95.00$238.00Q:4
/1Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK   3 Tier 3 Non-Preferred $95.00$238.00Q:6
/1Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
RISPERIODONE TABLET   1 Tier 1 Preferred Generic $5.00$10.00Q:6
/1Days
RITALIN 10MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RITALIN 20MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RITALIN 5MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RITALIN LA 10MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RITALIN LA 20MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RITALIN LA 30MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RITALIN LA 40MG CAPSULE   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RITALIN-SR 20MG TABLET SA   3 Tier 3 Non-Preferred $95.00$238.00None
RITUXAN 10MG/ML VIAL   5 Tier 5 Specialty 33%N/AP
ROBAXIN 100MG/ML VIAL   4 Tier 4 Injectable 33%N/ANone
ROBAXIN 500MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
ROBAXIN-750 TABLET 750MG   3 Tier 3 Non-Preferred $95.00$238.00None
ROBINUL 0.2MG/ML VIAL   4 Tier 4 Injectable 33%N/ANone
ROBINUL 1MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
ROBINUL FORTE 2MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
ROCALTROL 1MCG/ML ORAL TUBEX   3 Tier 3 Non-Preferred $95.00$238.00None
ROCALTROL CAPS 0.25MCG 100 EA   3 Tier 3 Non-Preferred $95.00$238.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ROCALTROL CAPS 0.5MCG 100 EA   3 Tier 3 Non-Preferred $95.00$238.00None
ROCEPHIN 1GM VIAL   4 Tier 4 Injectable 33%N/ANone
ROCEPHIN 2GM/DEXTROSE 2.4%   5 Tier 5 Specialty 33%N/ANone
ROCEPHIN/DEX INJ 1GM   4 Tier 4 Injectable 33%N/ANone
ROMYCIN 5MG/G OINTMENT   1 Tier 1 Preferred Generic $5.00$10.00None
ROPINIROLE HCL TABLET   1 Tier 1 Preferred Generic $5.00$10.00None
ROPINIROLE HCL TABLET 1 MG   1 Tier 1 Preferred Generic $5.00$10.00None
ROPINIROLE HCL TABLET 2 MG   1 Tier 1 Preferred Generic $5.00$10.00None
ROPINIROLE HCL TABLET 3 MG   1 Tier 1 Preferred Generic $5.00$10.00None
ROPINIROLE HCL TABLET 4 MG   1 Tier 1 Preferred Generic $5.00$10.00None
ROPINIROLE HCL TABLET 5 MG   1 Tier 1 Preferred Generic $5.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ROPINIROLE HYDROCLORIDE TABLET   1 Tier 1 Preferred Generic $5.00$10.00None
ROTATEQ VACCINE   3 Tier 3 Non-Preferred $95.00$238.00None
ROWASA RECTAL SUSPENSION ENEMA 4GM/60ML 7 X 60ML BOTUD   3 Tier 3 Non-Preferred $95.00$238.00None
ROXICET 5-325/5ML SOLUTION ORAL   2 Tier 2 Preferred Brand $35.00$70.00None
ROXICET 5/325 TABLET   1 Tier 1 Preferred Generic $5.00$10.00None
ROXICET 5/500 CAPLET   2 Tier 2 Preferred Brand $35.00$70.00None
ROXICODONE 15MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
ROXICODONE 30MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
ROZEREM 8MG TABLET (100 CT)   2 Tier 2 Preferred Brand $35.00$70.00S Q:1
/1Days
RYTHMOL 150MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RYTHMOL 225MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RYTHMOL 300MG TABLET   3 Tier 3 Non-Preferred $95.00$238.00None
RYTHMOL SR 225MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
RYTHMOL SR 425MG CAPSULE   2 Tier 2 Preferred Brand $35.00$70.00None
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES ER 325MG 60 BOT   2 Tier 2 Preferred Brand $35.00$70.00None
RYZOLT EXTENDED RELEASE TABLETS 100MG 30 BOT   3 Tier 3 Non-Preferred $95.00$238.00Q:3
/1Days
RYZOLT EXTENDED RELEASE TABLETS 200MG 30 BOT   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days
RYZOLT EXTENDED RELEASE TABLETS 300MG 30 BOT   3 Tier 3 Non-Preferred $95.00$238.00Q:1
/1Days

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D Health Net Orange Option 2 (PDP) 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 $310 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 $2830) 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 2010 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.