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

2011 Medicare Part D Plan Formulary Information
UA Medicare Part D Prescription Drug Cov (PDP) (S5755-005-0) Benefit Details
The UA Medicare Part D Prescription Drug Cov (PDP) (S5755-005-0) 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	2	Preferred Brand Name	$45.00	$90.00	None
RALOXIFENE 60 MG ORAL TABLET	2	Preferred Brand Name	$45.00	$90.00	Q:90 /90Days
RAMIPRIL 1.25MG CAPSULE	1*	Generic	$10.00	$26.00	None
RAMIPRIL 10MG CAPSULE	1*	Generic	$10.00	$26.00	None
RAMIPRIL 2.5MG CAPSULE	1*	Generic	$10.00	$26.00	None
RAMIPRIL 5MG CAPSULE	1*	Generic	$10.00	$26.00	None
RANEXA 1,000 MG TABLET	2	Preferred Brand Name	$45.00	$90.00	None
RANEXA 500 MG TABLET	2	Preferred Brand Name	$45.00	$90.00	None
RANITIDINE 150MG CAPSULE	1*	Generic	$10.00	$26.00	None
RANITIDINE HCL 15MG/ML SYRUP	1*	Generic	$10.00	$26.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE HCL 300MG CAPSULE (30 CT)	1*	Generic	$10.00	$26.00	None
RANITIDINE TABLET 300MG (100 CT)	1*	Generic	$10.00	$26.00	None
RANITIDINE TABLET USP 150MG (500 CT)	1*	Generic	$10.00	$26.00	None
RAPAMUNE 1MG TABLET	2	Preferred Brand Name	$45.00	$90.00	P
RAPAMUNE 1MG/ML ORAL TUBEX	2	Preferred Brand Name	$45.00	$90.00	P
RAPAMUNE 2MG TABLET	2	Preferred Brand Name	$45.00	$90.00	P
RAPAMUNE TABLETS	2	Preferred Brand Name	$45.00	$90.00	P
REBETOL 40MG/ML SOLUTION	2	Preferred Brand Name	$45.00	$90.00	P
REBIF 22MCG/0.5ML SYRINGE	4	Specialty	31%	31%	P Q:18 /90Days
REBIF 44MCG/0.5ML SYRINGE	4	Specialty	31%	31%	P Q:18 /90Days
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL	4	Specialty	31%	31%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RECLIPSEN 0.15-0.03 TABLET	1*	Generic	$10.00	$26.00	None
RECOMBIVAX HB 40MCG/ML VIAL	2	Preferred Brand Name	$45.00	$90.00	P
REGONOL AMP 10MG 5ML	1*	Generic	$10.00	$26.00	None
REGRANEX 0.01% GEL	2	Preferred Brand Name	$45.00	$90.00	P
RELENZA 5MG DISKHALER	2	Preferred Brand Name	$45.00	$90.00	Q:300 /365Days
RELION R INJ 100/ML	2	Preferred Brand Name	$45.00	$90.00	None
RELISTOR SOLUTION	2	Preferred Brand Name	$45.00	$90.00	None
RELPAX 20MG TABLET	2	Preferred Brand Name	$45.00	$90.00	Q:36 /90Days
RELPAX 40MG TABLET 6X2 BLPK	2	Preferred Brand Name	$45.00	$90.00	Q:36 /90Days
REMICADE 100MG VIAL	4	Specialty	31%	31%	P
RENAGEL 400MG TABLET	2	Preferred Brand Name	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RENAGEL 800MG TABLET	2	Preferred Brand Name	$45.00	$90.00	None
RENAMIN 6.5% IV SOLUTION	2	Preferred Brand Name	$45.00	$90.00	None
RENVELA 800MG TABLET	2	Preferred Brand Name	$45.00	$90.00	None
REPREXAIN TABLET	1*	Generic	$10.00	$26.00	None
REQUIP XL ROPINIROLE HCL 2MG	2	Preferred Brand Name	$45.00	$90.00	None
REQUIP XL ROPINIROLE HCL 4MG	2	Preferred Brand Name	$45.00	$90.00	None
REQUIP XL ROPINIROLE HCL 8MG	2	Preferred Brand Name	$45.00	$90.00	None
REQUIP XL TABLET 12 MG	2	Preferred Brand Name	$45.00	$90.00	None
RESCRIPTOR 100MG TABLET	3	Non-Preferred Brand Name	$95.00	$190.00	None
RESCRIPTOR 200MG TABLET	3	Non-Preferred Brand Name	$95.00	$190.00	None
RESERPINE 0.1MG TABLET	1*	Generic	$10.00	$26.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RESERPINE 0.25MG TABLET	1*	Generic	$10.00	$26.00	None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU	2	Preferred Brand Name	$45.00	$90.00	None
RETAPAMULIN 0.01 MG/MG TOPICAL OINTMENT [ALTABAX]	2	Preferred Brand Name	$45.00	$90.00	None
RETROVIR IV INFUSION VIAL	2	Preferred Brand Name	$45.00	$90.00	None
REVATIO 20MG TABLET	4	Specialty	31%	31%	P Q:270 /90Days
REVLIMID 10MG CAPSULE (100 CT)	4	Specialty	31%	31%	None
REVLIMID 15MG CAPSULE 21 BOT	4	Specialty	31%	31%	None
REVLIMID 25MG CAPSULE (100 CT)	4	Specialty	31%	31%	None
REVLIMID 5MG CAPSULE	4	Specialty	31%	31%	None
REYATAZ 100MG CAPSULE	2	Preferred Brand Name	$45.00	$90.00	None
REYATAZ 150MG CAPSULE	2	Preferred Brand Name	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REYATAZ 200MG CAPSULE	2	Preferred Brand Name	$45.00	$90.00	None
REYATAZ 300MG CAPSULE	2	Preferred Brand Name	$45.00	$90.00	None
RHEUMATREX 2.5MG TABLET DOSE PACK	3	Non-Preferred Brand Name	$95.00	$190.00	P
RHINOCORT AQUA NASAL SPRAY 32 MCG/SPRAY	3	Non-Preferred Brand Name	$95.00	$190.00	None
RIBAPAK 400-400MG TABLET DOSE PACK	4	Specialty	31%	31%	P
RIBAPAK 600-400MG TABLET DOSE PACK	4	Specialty	31%	31%	P
RIBAPAK 600-600MG TABLET DOSE PACK	4	Specialty	31%	31%	P
RIBASPHERE 200MG TABLET	1*	Generic	$10.00	$26.00	P
RIBASPHERE 400MG TABLET	4	Specialty	31%	31%	P
RIBASPHERE 600MG TABLET	4	Specialty	31%	31%	P
RIBASPHERE CAPSULES 200MG 42 BOT	4	Specialty	31%	31%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIBAVIRIN 200MG CAPSULE	4	Specialty	31%	31%	P
RIBAVIRIN 200MG TABLET 168 BOT	1*	Generic	$10.00	$26.00	P
RIDAURA 3MG CAPSULE	3	Non-Preferred Brand Name	$95.00	$190.00	None
RIFAMPIN 150MG CAPSULE (30 CT)	1*	Generic	$10.00	$26.00	None
RIFAMPIN 300MG CAPSULE	1*	Generic	$10.00	$26.00	None
RIFAMPIN 600MG VIAL	1*	Generic	$10.00	$26.00	None
RILUTEK 50MG TABLET	4	Specialty	31%	31%	None
RIMANTADINE 100MG TABLET	1*	Generic	$10.00	$26.00	None
RINGERS INJECTION 1000ML BAG	1*	Generic	$10.00	$26.00	None
RISPERDAL CONSTA 25MG SYR	2	Preferred Brand Name	$45.00	$90.00	None
RISPERDAL CONSTA 37.5MG SYR	2	Preferred Brand Name	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERDAL CONSTA 50MG SYR	2	Preferred Brand Name	$45.00	$90.00	None
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	2	Preferred Brand Name	$45.00	$90.00	None
RISPERIDONE 1 MG DISINTEGRATING TABLET	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR	1*	Generic	$10.00	$26.00	None
RISPERIDONE TABLET	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLET 1 MG	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLET 2 MG	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLET 3 MG	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLET 4 MG	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK	1*	Generic	$10.00	$26.00	Q:180 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK	1*	Generic	$10.00	$26.00	Q:180 /90Days
RISPERIODONE TABLET	1*	Generic	$10.00	$26.00	Q:180 /90Days
RITALIN LA 10MG CAPSULE	3	Non-Preferred Brand Name	$95.00	$190.00	P
RITALIN LA 20MG CAPSULE	3	Non-Preferred Brand Name	$95.00	$190.00	P
RITALIN LA 30MG CAPSULE	3	Non-Preferred Brand Name	$95.00	$190.00	P
RITALIN LA 40MG CAPSULE	3	Non-Preferred Brand Name	$95.00	$190.00	P
RITUXAN 10MG/ML VIAL	2	Preferred Brand Name	$45.00	$90.00	P
RIVASTIGMINE TARTRATE CAPSULES	1*	Generic	$10.00	$26.00	Q:180 /90Days
RIVASTIGMINE TARTRATE CAPSULES	1*	Generic	$10.00	$26.00	Q:180 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIVASTIGMINE TARTRATE CAPSULES	1*	Generic	$10.00	$26.00	Q:180 /90Days
RIVASTIGMINE TARTRATE CAPSULES	1*	Generic	$10.00	$26.00	Q:180 /90Days
ROMYCIN 5MG/G OINTMENT	1*	Generic	$10.00	$26.00	None
ROPINIROLE 6 MG EXTENDED RELEASE TABLET 24 HR [REQUIP]	2	Preferred Brand Name	$45.00	$90.00	None
ROPINIROLE HCL TABLET	1*	Generic	$10.00	$26.00	None
ROPINIROLE HCL TABLET 1 MG	1*	Generic	$10.00	$26.00	None
ROPINIROLE HCL TABLET 2 MG	1*	Generic	$10.00	$26.00	None
ROPINIROLE HCL TABLET 3 MG	1*	Generic	$10.00	$26.00	None
ROPINIROLE HCL TABLET 4 MG	1*	Generic	$10.00	$26.00	None
ROPINIROLE HCL TABLET 5 MG	1*	Generic	$10.00	$26.00	None
ROPINIROLE HYDROCLORIDE TABLET	1*	Generic	$10.00	$26.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROTATEQ VACCINE	2	Preferred Brand Name	$45.00	$90.00	None
ROXICET 5-325/5ML SOLUTION ORAL	2	Preferred Brand Name	$45.00	$90.00	None
ROXICET 5/325 TABLET	1*	Generic	$10.00	$26.00	None
ROZEREM 8MG TABLET (100 CT)	3	Non-Preferred Brand Name	$95.00	$190.00	None
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES ER 325MG 60 BOT	2	Preferred Brand Name	$45.00	$90.00	None
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE 225 MG	2	Preferred Brand Name	$45.00	$90.00	None
RYTHMOL SR PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE 425 MG	2	Preferred Brand Name	$45.00	$90.00	None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D UA Medicare Part D Prescription Drug Cov (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.