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2014 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Choice (PDP) (S5660-205-0) Benefit Details
The Express Scripts Medicare - Choice (PDP) (S5660-205-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 38 which includes: PR Plan Monthly Premium: $57.00 Deductible: $0 Qualifies for LIS: No
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
Rabeprazole Sodium DR 20 MG Tablet [AcipHex]	2	Non-Preferred Generic	$10.00	$20.00	None
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL	3	Preferred Brand	$40.00	$100.00	None
RAGWITEK SUBLINGUAL TABLET	3	Preferred Brand	$40.00	$100.00	None
Raloxifene HCl 60 mg tablet [Evista]	2	Non-Preferred Generic	$10.00	$20.00	None
RAMIPRIL 1.25MG CAPSULE	2	Non-Preferred Generic	$10.00	$20.00	None
RAMIPRIL 10MG CAPSULE	2	Non-Preferred Generic	$10.00	$20.00	None
RAMIPRIL 2.5MG CAPSULE	2	Non-Preferred Generic	$10.00	$20.00	None
RAMIPRIL 5MG CAPSULE	2	Non-Preferred Generic	$10.00	$20.00	None
RANEXA ER 1,000 MG TABLET	3	Preferred Brand	$40.00	$100.00	None
RANEXA ER 500 MG TABLET	3	Preferred Brand	$40.00	$100.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE 150MG CAPSULE	1	Preferred Generic	$2.00	$0.00	None
Ranitidine 16.8mg/mL 473 mL in 1 BOTTLE	2	Non-Preferred Generic	$10.00	$20.00	None
Ranitidine 300mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$2.00	$0.00	None
Ranitidine Hydrochloride 300mg/1 30 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$0.00	None
RANITIDINE TABLET USP 150MG (500 CT)	1	Preferred Generic	$2.00	$0.00	None
RAPAMUNE 0.5MG TABLETS	3	Preferred Brand	$40.00	$100.00	P
RAPAMUNE 1MG TABLET	3	Preferred Brand	$40.00	$100.00	P
RAPAMUNE 1MG/ML ORAL TUBEX	3	Preferred Brand	$40.00	$100.00	P
RAPAMUNE 2MG TABLET	5	Specialty Tier	33%	N/A	P
RAVICTI 1.1 GRAM/ML LIQUID	5	Specialty Tier	33%	N/A	None
REBETOL 40MG/ML SOLUTION	3	Preferred Brand	$40.00	$100.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS	5	Specialty Tier	33%	N/A	P Q:6 /28Days
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS	5	Specialty Tier	33%	N/A	P Q:6 /28Days
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL	5	Specialty Tier	33%	N/A	P Q:12 /28Days
RECLAST 5MG/100ML INJECTION	3	Preferred Brand	$40.00	$100.00	None
RECLIPSEN 0.15-0.03 TABLET	2	Non-Preferred Generic	$10.00	$20.00	None
RECOMBIVAX HB 40MCG/ML VIAL	3	Preferred Brand	$40.00	$100.00	P
RECTIV 0.4% OINTMENT	3	Preferred Brand	$40.00	$100.00	None
REGRANEX 0.01% GEL	3	Preferred Brand	$40.00	$100.00	P Q:45 /90Days
RELENZA 5MG DISKHALER	3	Preferred Brand	$40.00	$100.00	Q:60 /180Days
RELISTOR 12 MG/0.6 ML KIT	3	Preferred Brand	$40.00	$100.00	None
RELPAX 20MG TABLET	3	Preferred Brand	$40.00	$100.00	Q:54 /84Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RELPAX 40MG TABLET 6X2 BLPK	3	Preferred Brand	$40.00	$100.00	Q:54 /84Days
REMICADE 100MG VIAL	5	Specialty Tier	33%	N/A	P
REMODULIN 10MG/ML VIAL	5	Specialty Tier	33%	N/A	P
REMODULIN 1MG/ML VIAL	5	Specialty Tier	33%	N/A	P
REMODULIN 2.5MG/ML VIAL	5	Specialty Tier	33%	N/A	P
REMODULIN 5MG/ML VIAL	5	Specialty Tier	33%	N/A	P
RENVELA 800MG TABLET	3	Preferred Brand	$40.00	$100.00	None
Repaglinide 0.5 MG Tablet [Prandin]	2	Non-Preferred Generic	$10.00	$20.00	None
Repaglinide 1 MG Tablet [Prandin]	2	Non-Preferred Generic	$10.00	$20.00	None
Repaglinide 2 MG Tablet [Prandin]	2	Non-Preferred Generic	$10.00	$20.00	None
Reprexain 10-200 mg tablet	2	Non-Preferred Generic	$10.00	$20.00	Q:150 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RESCRIPTOR 100mg/1 360 TABLET BOTTLE	3	Preferred Brand	$40.00	$100.00	None
RESCRIPTOR 200 MG TABLET	3	Preferred Brand	$40.00	$100.00	None
RESERPINE 0.1MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	None
Reserpine 0.25mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$10.00	$20.00	None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU	3	Preferred Brand	$40.00	$100.00	Q:180 /90Days
RETROVIR 10mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 20 mL in 1 VIAL, SINGLE-USE	3	Preferred Brand	$40.00	$100.00	None
Revatio 0.8mg/mL 12.5 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	33%	N/A	P
REVATIO 20MG TABLET	5	Specialty Tier	33%	N/A	P Q:93 /31Days
REVLIMID 10MG CAPSULE (100 CT)	5	Specialty Tier	33%	N/A	None
REVLIMID 15MG CAPSULE 21 BOT	5	Specialty Tier	33%	N/A	None
REVLIMID 2.5 MG CAPSULE	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REVLIMID 20 MG CAPSULE	5	Specialty Tier	33%	N/A	None
REVLIMID 25MG CAPSULE (100 CT)	5	Specialty Tier	33%	N/A	None
REVLIMID 5MG CAPSULE	5	Specialty Tier	33%	N/A	None
REYATAZ 100MG CAPSULE	3	Preferred Brand	$40.00	$100.00	None
REYATAZ 150MG CAPSULE	5	Specialty Tier	33%	N/A	None
REYATAZ 200MG CAPSULE	5	Specialty Tier	33%	N/A	None
REYATAZ 300MG CAPSULE	5	Specialty Tier	33%	N/A	None
RHEUMATREX 2.5MG TABLET DOSE PACK	4	Non-Preferred Brand	$90.00	$225.00	P
RIBASPHERE 200MG TABLET	3	Preferred Brand	$40.00	$100.00	None
RIBASPHERE 400MG TABLET	3	Preferred Brand	$40.00	$100.00	None
RIBASPHERE 600MG TABLET	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIBASPHERE CAPSULES 200MG 42 BOT	3	Preferred Brand	$40.00	$100.00	None
RIBASPHERE RibaPak	5	Specialty Tier	33%	N/A	None
RIBASPHERE RibaPak 400mg/1	5	Specialty Tier	33%	N/A	None
RIBASPHERE RibaPak 600mg/1	5	Specialty Tier	33%	N/A	None
RIBAVIRIN 200 MG CAPSULE	3	Preferred Brand	$40.00	$100.00	None
RIBAVIRIN 200MG TABLET 168 BOT	3	Preferred Brand	$40.00	$100.00	None
RIDAURA 3MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
RIFABUTIN 150 MG CAPSULE [Mycobutin]	2	Non-Preferred Generic	$10.00	$20.00	None
RIFAMPIN 150MG CAPSULE (30 CT)	2	Non-Preferred Generic	$10.00	$20.00	None
RIFAMPIN 300MG CAPSULE	2	Non-Preferred Generic	$10.00	$20.00	None
RIFAMPIN 600MG VIAL	2	Non-Preferred Generic	$10.00	$20.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
riluzole 50 mg tablet [Rilutek]	5	Specialty Tier	33%	N/A	None
Rimantadine 100mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$10.00	$20.00	None
RINGERS 33/30/860 INJECTION	2	Non-Preferred Generic	$10.00	$20.00	None
RIOMET 500MG/5ML SOLUTION ORAL	3	Preferred Brand	$40.00	$100.00	Q:2295 /90Days
RISPERDAL CONSTA 25MG SYR	3	Preferred Brand	$40.00	$100.00	None
RISPERDAL CONSTA 37.5MG SYR	5	Specialty Tier	33%	N/A	None
RISPERDAL CONSTA 50MG SYR	5	Specialty Tier	33%	N/A	None
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	3	Preferred Brand	$40.00	$100.00	None
RISPERIDONE 0.25 MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	Q:5760 /90Days
RISPERIDONE 0.5 MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	Q:2880 /90Days
RISPERIDONE 1 MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	Q:1440 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Risperidone 1mg/1 7 BLISTER PACK per CARTON / 4 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Non-Preferred Generic	$10.00	$20.00	Q:1440 /90Days
Risperidone 1mg/mL 30 mL in 1 BOTTLE	2	Non-Preferred Generic	$10.00	$20.00	Q:1440 /90Days
RISPERIDONE 2 MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	Q:720 /90Days
RISPERIDONE 3 MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	Q:482 /90Days
RISPERIDONE 4 MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	Q:360 /90Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	2	Non-Preferred Generic	$10.00	$20.00	Q:5760 /90Days
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK	2	Non-Preferred Generic	$10.00	$20.00	Q:482 /90Days
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK	2	Non-Preferred Generic	$10.00	$20.00	Q:360 /90Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK	2	Non-Preferred Generic	$10.00	$20.00	Q:2880 /90Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK	2	Non-Preferred Generic	$10.00	$20.00	Q:720 /90Days
RITALIN LA 10MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RITALIN LA 20MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
RITALIN LA 30MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
RITALIN LA 40MG CAPSULE	4	Non-Preferred Brand	$90.00	$225.00	None
RITUXAN 10MG/ML VIAL	5	Specialty Tier	33%	N/A	P
RIVASTIGMINE TARTRATE 3MG CAPSULES	2	Non-Preferred Generic	$10.00	$20.00	None
RIVASTIGMINE TARTRATE 4.5MG CAPSULES	2	Non-Preferred Generic	$10.00	$20.00	None
RIVASTIGMINE TARTRATE 6MG CAPSULES	2	Non-Preferred Generic	$10.00	$20.00	None
RIVASTIGMINE TARTRATE1.5MG CAPSULES	2	Non-Preferred Generic	$10.00	$20.00	None
rizatriptan 10 mg odt	2	Non-Preferred Generic	$10.00	$20.00	Q:108 /84Days
rizatriptan 10 mg tablet	2	Non-Preferred Generic	$10.00	$20.00	Q:108 /84Days
rizatriptan 5 mg odt	2	Non-Preferred Generic	$10.00	$20.00	Q:108 /84Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
rizatriptan 5 mg tablet	2	Non-Preferred Generic	$10.00	$20.00	Q:108 /84Days
ROPINIROLE HCL 0.5MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE HCL TABLET 1 MG	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE HCL TABLET 2 MG	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE HCL TABLET 3 MG	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE HCL TABLET 4 MG	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE HCL TABLET 5 MG	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE HYDROCLORIDE 0.25MG TABLET	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE TAB 12MG ER	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE TAB 2MG ER	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE TAB 4MG ER	2	Non-Preferred Generic	$10.00	$20.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROPINIROLE TAB 6MG ER	2	Non-Preferred Generic	$10.00	$20.00	None
ROPINIROLE TAB 8MG ER	2	Non-Preferred Generic	$10.00	$20.00	None
ROTATEQ VACCINE	3	Preferred Brand	$40.00	$100.00	None
ROXICET 5-325/5ML SOLUTION ORAL	3	Preferred Brand	$40.00	$100.00	Q:2400 /90Days
ROZEREM 8MG TABLET (100 CT)	3	Preferred Brand	$40.00	$100.00	Q:90 /90Days

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Express Scripts Medicare - 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 September 2014 )

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.