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2013 Medicare Part D Plan Formulary Information
EnvisionRxPlus Gold (PDP) (S7694-079-0) Benefit Details
The EnvisionRxPlus Gold (PDP) (S7694-079-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 8 which includes: NC
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	4	Non-Preferred Brand	30%	30%	P
RAMIPRIL 1.25MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
RAMIPRIL 10MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
RAMIPRIL 2.5MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
RAMIPRIL 5MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
RANEXA ER 1,000 MG TABLET	3	Preferred Brand	1%	1%	None
RANEXA ER 500 MG TABLET	3	Preferred Brand	1%	1%	None
RANITIDINE 150MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE HCL 25MG/ML VIAL	2	Non-Preferred Generic	1%	1%	None
Ranitidine Hydrochloride 300mg/1 30 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
RANITIDINE TABLET USP 150MG (500 CT)	1	Preferred Generic	1%	1%	None
RAPAFLO CAPSULES 4MG 30 BOT	3	Preferred Brand	1%	1%	None
RAPAFLO CAPSULES 8MG 90 BOT	3	Preferred Brand	1%	1%	None
RAPAMUNE 1MG TABLET	4	Non-Preferred Brand	30%	30%	P
RAPAMUNE 1MG/ML ORAL TUBEX	3	Preferred Brand	1%	1%	P
RAPAMUNE 2MG TABLET	4	Non-Preferred Brand	30%	30%	P
RAPAMUNE TABLETS	4	Non-Preferred Brand	30%	30%	P
RAZADYNE SOL 4MG/ML	3	Preferred Brand	1%	1%	None
RECLAST INJECTION	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RECOMBIVAX HB 40MCG/ML VIAL	4	Non-Preferred Brand	30%	30%	P
REGRANEX 0.01% GEL	5	Specialty Tier	29%	N/A	None
RELISTOR 12 MG/0.6 ML KIT	4	Non-Preferred Brand	30%	30%	None
RELPAX 20MG TABLET	3	Preferred Brand	1%	1%	Q:9 /30Days
RELPAX 40MG TABLET 6X2 BLPK	3	Preferred Brand	1%	1%	Q:9 /30Days
REMICADE 100MG VIAL	5	Specialty Tier	29%	N/A	None
RENVELA 800MG TABLET	4	Non-Preferred Brand	30%	30%	None
RESCRIPTOR 100mg/1 360 TABLET BOTTLE	3	Preferred Brand	1%	1%	None
RESCRIPTOR 200 MG TABLET	3	Preferred Brand	1%	1%	None
RESERPINE 0.1MG TABLET	1	Preferred Generic	1%	1%	None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE	4	Non-Preferred Brand	30%	30%	None
Revatio 0.8mg/mL 12.5 mL in 1 VIAL, SINGLE-USE	3	Preferred Brand	1%	1%	P
REVLIMID 10MG CAPSULE (100 CT)	5	Specialty Tier	29%	N/A	None
REVLIMID 15MG CAPSULE 21 BOT	5	Specialty Tier	29%	N/A	None
REVLIMID 25MG CAPSULE (100 CT)	5	Specialty Tier	29%	N/A	None
REVLIMID 5MG CAPSULE	5	Specialty Tier	29%	N/A	None
REYATAZ 100MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
REYATAZ 150MG CAPSULE	5	Specialty Tier	29%	N/A	None
REYATAZ 200MG CAPSULE	5	Specialty Tier	29%	N/A	None
REYATAZ 300MG CAPSULE	5	Specialty Tier	29%	N/A	None
RHEUMATREX 2.5MG TABLET DOSE PACK	4	Non-Preferred Brand	30%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIBASPHERE 200MG TABLET	2	Non-Preferred Generic	1%	1%	None
RIBASPHERE 400MG TABLET	2	Non-Preferred Generic	1%	1%	None
RIBASPHERE CAPSULES 200MG 42 BOT	2	Non-Preferred Generic	1%	1%	None
RIBASPHERE RibaPak	5	Specialty Tier	29%	N/A	None
RIBASPHERE RibaPak 400mg/1	5	Specialty Tier	29%	N/A	None
RIBAVIRIN 200MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
RIBAVIRIN 200MG TABLET 168 BOT	2	Non-Preferred Generic	1%	1%	None
RIFAMPIN 150MG CAPSULE (30 CT)	1	Preferred Generic	1%	1%	None
RIFAMPIN 300MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
RIFAMPIN 600MG VIAL	1	Preferred Generic	1%	1%	None
RILUTEK 50MG TABLET	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Rimantadine 100mg/1 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	None
RINGERS INJECTION 1000ML BAG	1	Preferred Generic	1%	1%	None
RINGERS IRRIGATION 860-30 12X1000ML BAG	1	Preferred Generic	1%	1%	None
RISPERDAL CONSTA 25MG SYR	4	Non-Preferred Brand	30%	30%	None
RISPERDAL CONSTA 37.5MG SYR	5	Specialty Tier	29%	N/A	None
RISPERDAL CONSTA 50MG SYR	5	Specialty Tier	29%	N/A	None
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	4	Non-Preferred Brand	30%	30%	None
Risperidone 1mg/1 7 BLISTER PACK in 1 CARTON / 4 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	2	Non-Preferred Generic	1%	1%	None
Risperidone 1mg/mL 30 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLET	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE TABLET 1 MG	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLET 2 MG	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLET 3 MG	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLET 4 MG	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK	2	Non-Preferred Generic	1%	1%	None
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK	2	Non-Preferred Generic	1%	1%	None
RISPERIODONE TABLET	2	Non-Preferred Generic	1%	1%	None
RITUXAN 10MG/ML VIAL	5	Specialty Tier	29%	N/A	None
RIVASTIGMINE TARTRATE CAPSULES	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIVASTIGMINE TARTRATE CAPSULES	2	Non-Preferred Generic	1%	1%	None
RIVASTIGMINE TARTRATE CAPSULES	2	Non-Preferred Generic	1%	1%	None
RIVASTIGMINE TARTRATE CAPSULES	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HCL TABLET	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HCL TABLET 1 MG	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HCL TABLET 2 MG	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HCL TABLET 3 MG	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HCL TABLET 4 MG	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HCL TABLET 5 MG	2	Non-Preferred Generic	1%	1%	None
ROPINIROLE HYDROCLORIDE TABLET	2	Non-Preferred Generic	1%	1%	None
ROTATEQ VACCINE	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROXICET 5-325/5ML SOLUTION ORAL	2	Non-Preferred Generic	1%	1%	Q:1850 /30Days
ROXICET 5/500 CAPLET	2	Non-Preferred Generic	1%	1%	Q:240 /30Days
ROXICODONE TABLETS 5 MG	2	Non-Preferred Generic	1%	1%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D EnvisionRxPlus Gold (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 $325 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 $2970) 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 2013 )

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.