Q1Medicare.com 2011 Medicare Part D or Medicare Advantage Plan Formulary Browser

2011 Medicare Part D Plan Formulary Information
Community CCRx Choice (PDP) (S5803-138-0) Benefit Details
The Community CCRx Choice (PDP) (S5803-138-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 01 which includes: ME NH
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
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
RALOXIFENE 60 MG ORAL TABLET	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:30 /30Days
RAMIPRIL 1.25MG CAPSULE	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RAMIPRIL 10MG CAPSULE	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RAMIPRIL 2.5MG CAPSULE	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RAMIPRIL 5MG CAPSULE	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RANEXA 1,000 MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	S Q:60 /30Days
RANEXA 500 MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	S Q:90 /30Days
RANITIDINE HCL 15MG/ML SYRUP	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
RANITIDINE TABLET 300MG (100 CT)	1	Generic and Preferred Brand	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE TABLET USP 150MG (500 CT)	1	Generic and Preferred Brand	$0.00	N/A	None
RAPAMUNE 1MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	P
RAPAMUNE 1MG/ML ORAL TUBEX	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	P
RAPAMUNE 2MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	P
RAPAMUNE TABLETS	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	P
REBETOL 40MG/ML SOLUTION	4	Specialty Tier	33%	N/A	P
RECLIPSEN 0.15-0.03 TABLET	1	Generic and Preferred Brand	$0.00	N/A	Q:28 /28Days
RECOMBIVAX HB 40MCG/ML VIAL	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	P
REGRANEX 0.01% GEL	4	Specialty Tier	33%	N/A	P Q:15 /30Days
RELENZA 5MG DISKHALER	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	Q:60 /30Days
REMICADE 100MG VIAL	4	Specialty Tier	33%	N/A	P
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 Generic/ Non-Preferred Brand	$65.00	N/A	P
RENVELA 800MG TABLET	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
RESCRIPTOR 100MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
RESCRIPTOR 200MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:64 /30Days
RETROVIR IV INFUSION VIAL	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
REVATIO 20MG TABLET	4	Specialty Tier	33%	N/A	P Q:90 /30Days
REVLIMID 10MG CAPSULE (100 CT)	4	Specialty Tier	33%	N/A	P Q:30 /30Days
REVLIMID 15MG CAPSULE 21 BOT	4	Specialty Tier	33%	N/A	P Q:30 /30Days
REVLIMID 25MG CAPSULE (100 CT)	4	Specialty Tier	33%	N/A	P Q:21 /28Days
REVLIMID 5MG CAPSULE	4	Specialty Tier	33%	N/A	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REYATAZ 100MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
REYATAZ 150MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
REYATAZ 200MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
REYATAZ 300MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
RIBASPHERE 200MG TABLET	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	P
RIBASPHERE 400MG TABLET	4	Specialty Tier	33%	N/A	P
RIBASPHERE 600MG TABLET	4	Specialty Tier	33%	N/A	P
RIBASPHERE CAPSULES 200MG 42 BOT	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	P
RIBAVIRIN 200MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	P
RIBAVIRIN 200MG TABLET 168 BOT	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	P
RIBAVIRIN TABLETS 400MG 56 TABS BOT	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIBAVIRIN TABLETS 600MG 56 TABS BOT	4	Specialty Tier	33%	N/A	P
RIDAURA 3MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
RIFAMPIN 150MG CAPSULE (30 CT)	1	Generic and Preferred Brand	$0.00	N/A	None
RIFAMPIN 300MG CAPSULE	1	Generic and Preferred Brand	$0.00	N/A	None
RIFAMPIN 600MG VIAL	4	Specialty Tier	33%	N/A	None
RIFATER TABLET	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	None
RILUTEK 50MG TABLET	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	P
RIMANTADINE 100MG TABLET	1	Generic and Preferred Brand	$0.00	N/A	None
RINGERS INJECTION 1000ML BAG	1	Generic and Preferred Brand	$0.00	N/A	None
RINGERS IRRIGATION 860-30 12X1000ML BAG	1	Generic and Preferred Brand	$0.00	N/A	None
RIOMET 500MG/5ML SOLUTION ORAL	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	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 Generic/ Non-Preferred Brand	$65.00	N/A	P Q:2 /28Days
RISPERDAL CONSTA 37.5MG SYR	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	P Q:2 /28Days
RISPERDAL CONSTA 50MG SYR	4	Specialty Tier	33%	N/A	P Q:2 /28Days
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	P Q:2 /28Days
RISPERIDONE 1 MG DISINTEGRATING TABLET	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:60 /30Days
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:240 /30Days
RISPERIDONE TABLET	1	Generic and Preferred Brand	$0.00	N/A	Q:90 /30Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:90 /30Days
RISPERIDONE TABLET 1 MG	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RISPERIDONE TABLET 2 MG	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RISPERIDONE TABLET 3 MG	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE TABLET 4 MG	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:60 /30Days
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:60 /30Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:90 /30Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK	2	Non-Preferred Generic/Preferred Brand	$35.00	N/A	Q:60 /30Days
RISPERIODONE TABLET	1	Generic and Preferred Brand	$0.00	N/A	Q:90 /30Days
RITUXAN 10MG/ML VIAL	4	Specialty Tier	33%	N/A	P
RIVASTIGMINE TARTRATE CAPSULES	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RIVASTIGMINE TARTRATE CAPSULES	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RIVASTIGMINE TARTRATE CAPSULES	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
RIVASTIGMINE TARTRATE CAPSULES	1	Generic and Preferred Brand	$0.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROMYCIN 5MG/G OINTMENT	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HCL TABLET	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HCL TABLET 1 MG	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HCL TABLET 2 MG	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HCL TABLET 3 MG	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HCL TABLET 4 MG	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HCL TABLET 5 MG	1	Generic and Preferred Brand	$0.00	N/A	None
ROPINIROLE HYDROCLORIDE TABLET	1	Generic and Preferred Brand	$0.00	N/A	None
ROTATEQ VACCINE	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
ROXICET 5/325 TABLET	1	Generic and Preferred Brand	$0.00	N/A	Q:360 /30Days
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES ER 325MG 60 BOT	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE 225 MG	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE 425 MG	3	Non-Preferred Generic/ Non-Preferred Brand	$65.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Community CCRx Choice (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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.