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MedicareBlue Rx Standard (PDP) (S5743-001-0)
Tier 1 (1626)
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Tier 4 (212)

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2010 Medicare Part D Plan Formulary Information
MedicareBlue Rx Standard (PDP) (S5743-001-0)
Benefit Details  
The MedicareBlue Rx Standard (PDP) (S5743-001-0)
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
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL   3 Level 3: Covered Brand 50%50%None
RAMIPRIL 1.25MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RAMIPRIL 10MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RAMIPRIL 2.5MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RAMIPRIL 5MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RANEXA 1000MG TABLET SR 12HR   3 Level 3: Covered Brand 50%50%None
RANEXA 500MG TABLET   3 Level 3: Covered Brand 50%50%None
RANITIDINE 150MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RANITIDINE HCL 15MG/ML SYRUP   1 Level 1: Covered Generics 10%10%None
RANITIDINE HCL 300MG CAPSULE (30 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RANITIDINE TABLET 300MG (100 CT)   1 Level 1: Covered Generics 10%10%None
RANITIDINE TABLET USP 150MG (500 CT)   1 Level 1: Covered Generics 10%10%None
RAPAMUNE 1MG TABLET   2 Level 2: Covered Preferred Brand 22%22%P
RAPAMUNE 1MG/ML ORAL TUBEX   2 Level 2: Covered Preferred Brand 22%22%P
RAPAMUNE 2MG TABLET   2 Level 2: Covered Preferred Brand 22%22%P
RAZADYNE SOL 4MG/ML   3 Level 3: Covered Brand 50%50%None
REBETOL 40MG/ML SOLUTION   4 Covered Specialty 25%25%None
RECLIPSEN 0.15-0.03 TABLET   1 Level 1: Covered Generics 10%10%None
RECOMBIVAX HB 40MCG/ML VIAL   3 Level 3: Covered Brand 50%50%P
REMICADE 100MG VIAL   4 Covered Specialty 25%25%S
REMODULIN 10MG/ML VIAL   4 Covered Specialty 25%25%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
REMODULIN 1MG/ML VIAL   4 Covered Specialty 25%25%P
REMODULIN 2.5MG/ML VIAL   4 Covered Specialty 25%25%P
REMODULIN 5MG/ML VIAL   4 Covered Specialty 25%25%P
RENVELA 800MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
REPREXAIN TABLET   1 Level 1: Covered Generics 10%10%None
RESCRIPTOR 100MG TABLET   3 Level 3: Covered Brand 50%50%None
RESCRIPTOR 200MG TABLET   3 Level 3: Covered Brand 50%50%None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU   2 Level 2: Covered Preferred Brand 22%22%None
RETROVIR IV INFUSION VIAL   3 Level 3: Covered Brand 50%50%None
REVATIO 20MG TABLET   4 Covered Specialty 25%25%P
REVLIMID 10MG CAPSULE (100 CT)   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
REVLIMID 15MG CAPSULE 21 BOT   4 Covered Specialty 25%25%None
REVLIMID 25MG CAPSULE (100 CT)   4 Covered Specialty 25%25%None
REVLIMID 5MG CAPSULE   4 Covered Specialty 25%25%None
REYATAZ 100MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
REYATAZ 150MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
REYATAZ 200MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
REYATAZ 300MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY   3 Level 3: Covered Brand 50%50%Q:17
/30Days
RIBAPAK 400-400MG TABLET DOSE PACK   1 Level 1: Covered Generics 10%10%None
RIBAPAK 600-600MG TABLET DOSE PACK   1 Level 1: Covered Generics 10%10%None
RIBASPHERE 200MG TABLET   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RIBASPHERE 400MG TABLET   1 Level 1: Covered Generics 10%10%None
RIBASPHERE 600MG TABLET   1 Level 1: Covered Generics 10%10%None
RIBASPHERE CAPSULES 200MG 42 BOT   1 Level 1: Covered Generics 10%10%None
RIBAVIRIN 200MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RIBAVIRIN 200MG TABLET 168 BOT   1 Level 1: Covered Generics 10%10%None
RIBAVIRIN TABLETS 400MG 56 TABS BOT   1 Level 1: Covered Generics 10%10%None
RIBAVIRIN TABLETS 600MG 56 TABS BOT   1 Level 1: Covered Generics 10%10%None
RIFAMPIN 150MG CAPSULE (30 CT)   1 Level 1: Covered Generics 10%10%None
RIFAMPIN 300MG CAPSULE   1 Level 1: Covered Generics 10%10%None
RIFAMPIN 600MG VIAL   1 Level 1: Covered Generics 10%10%None
RILUTEK 50MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RIMANTADINE 100MG TABLET   1 Level 1: Covered Generics 10%10%None
RISPERDAL 1MG M-TAB   3 Level 3: Covered Brand 50%50%S Q:60
/30Days
RISPERDAL CONSTA 25MG SYR   3 Level 3: Covered Brand 50%50%S Q:2
/28Days
RISPERDAL CONSTA 37.5MG SYR   3 Level 3: Covered Brand 50%50%S Q:2
/28Days
RISPERDAL CONSTA 50MG SYR   3 Level 3: Covered Brand 50%50%S Q:2
/28Days
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL   3 Level 3: Covered Brand 50%50%S Q:2
/28Days
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR   1 Level 1: Covered Generics 10%10%Q:480
/30Days
RISPERIDONE TABLET   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK   3 Level 3: Covered Brand 50%50%S Q:60
/30Days
RISPERIDONE TABLET 1 MG   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RISPERIDONE TABLET 2 MG   1 Level 1: Covered Generics 10%10%Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RISPERIDONE TABLET 3 MG   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RISPERIDONE TABLET 4 MG   1 Level 1: Covered Generics 10%10%Q:120
/30Days
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK   1 Level 1: Covered Generics 10%10%Q:120
/30Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RISPERIODONE TABLET   1 Level 1: Covered Generics 10%10%Q:60
/30Days
RITUXAN 10MG/ML VIAL   4 Covered Specialty 25%25%S
ROMYCIN 5MG/G OINTMENT   1 Level 1: Covered Generics 10%10%None
ROPINIROLE HCL TABLET   1 Level 1: Covered Generics 10%10%None
ROPINIROLE HCL TABLET 1 MG   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ROPINIROLE HCL TABLET 2 MG   1 Level 1: Covered Generics 10%10%None
ROPINIROLE HCL TABLET 3 MG   1 Level 1: Covered Generics 10%10%None
ROPINIROLE HCL TABLET 4 MG   1 Level 1: Covered Generics 10%10%None
ROPINIROLE HCL TABLET 5 MG   1 Level 1: Covered Generics 10%10%None
ROPINIROLE HYDROCLORIDE TABLET   1 Level 1: Covered Generics 10%10%None
ROTATEQ VACCINE   3 Level 3: Covered Brand 50%50%None
ROXICET 5/325 TABLET   1 Level 1: Covered Generics 10%10%None
RYTHMOL SR 225MG CAPSULE   3 Level 3: Covered Brand 50%50%None
RYTHMOL SR 425MG CAPSULE   3 Level 3: Covered Brand 50%50%None
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES ER 325MG 60 BOT   3 Level 3: Covered Brand 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D MedicareBlue Rx Standard (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.