2018 Medicare Part D Plan Formulary Information |
Gateway Health Medicare Assured Diamond (HMO SNP) (H9190-001-0)
Benefit Details
|
The Gateway Health Medicare Assured Diamond (HMO SNP) (H9190-001-0) Formulary Drugs Starting with the Letter R in Morrow County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $31.90 Deductible: $405 |
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 |
RABAVERT RABIES VACCINE VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex] |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RALOXIFENE HCL 60 MG TABLET [Evista] |
1 |
Tier 1 |
$0.00 | N/A | None |
RAMIPRIL 1.25 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RAMIPRIL 10 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RAMIPRIL 2.5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RAMIPRIL 5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RANEXA ER 1,000 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
RANEXA ER 500 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:120 /30Days |
RANITIDINE 15 MG/ML SYRUP |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE 150 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RANITIDINE 150 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RANITIDINE 300 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RANITIDINE 300 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RANITIDINE HCL 50 MG/2 ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
RAPAMUNE 1MG/ML ORAL TUBEX |
1 |
Tier 1 |
$0.00 | N/A | P |
Rasagiline Mesylate 0.5 MG TABLET [Azilect] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
Rasagiline Mesylate 1 MG TABLET [Azilect] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RAVICTI 1.1 GRAM/ML LIQUID |
1 |
Tier 1 |
$0.00 | N/A | P |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REBIF REBIDOSE 22 MCG/0.5 ML |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /28Days |
REBIF REBIDOSE TITRATION PACK |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /28Days |
RECLIPSEN 28 DAY TABLET [Solia] |
1 |
Tier 1 |
$0.00 | N/A | None |
RECOMBIVAX HB 10 MCG/ML SYR |
1 |
Tier 1 |
$0.00 | N/A | P |
RECOMBIVAX HB 40MCG/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
RELENZA 5MG DISKHALER |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /180Days |
RELISTOR 12 MG/0.6 ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P Q:18 /30Days |
RELISTOR 150 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
RELISTOR 8 MG/0.4 ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REMICADE 100MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
RENVELA 800MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
1 |
Tier 1 |
$0.00 | N/A | None |
REPAGLINIDE 1 MG TABLET [Prandin] |
1 |
Tier 1 |
$0.00 | N/A | Q:120 /30Days |
REPAGLINIDE 2 MG TABLET [Prandin] |
1 |
Tier 1 |
$0.00 | N/A | Q:240 /30Days |
REPATHA 140 MG/ML SURECLICK |
1 |
Tier 1 |
$0.00 | N/A | P Q:3 /28Days |
REPATHA 140 MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | N/A | P Q:3 /28Days |
REPATHA 420 MG/3.5ML PUSHTRONX |
1 |
Tier 1 |
$0.00 | N/A | P Q:4 /28Days |
RESCRIPTOR 100mg/1 360 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
RESCRIPTOR 200 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RESTASIS 0.05% EYE EMULSION |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETROVIR 200 MG/20 ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
REVLIMID 10 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REVLIMID 15MG CAPSULE 21 BOT |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REVLIMID 2.5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REVLIMID 20 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REVLIMID 25 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REVLIMID 5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REXULTI 0.25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:120 /30Days |
REXULTI 0.5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
REXULTI 1 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:120 /30Days |
REXULTI 2 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 3 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REXULTI 4 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P Q:30 /30Days |
REYATAZ 150MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
REYATAZ 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
REYATAZ 300MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
REYATAZ 50 MG POWDER PACKET |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE 200 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE 200MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE 400MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE 600MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE RibaPak |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ribasphere RibaPak 200-400 mg |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE RibaPak 400mg/1 |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBASPHERE RibaPak 600mg/1 |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBAVIRIN 200 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RIBAVIRIN 200MG TABLET 168 BOT |
1 |
Tier 1 |
$0.00 | N/A | None |
RIDAURA 3 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
1 |
Tier 1 |
$0.00 | N/A | None |
RIFAMATE 150/300 CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RIFAMPIN 150 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RIFAMPIN 300 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | None |
RIFAMPIN IV 600 MG VIAL |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFATER 50/300/120 TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
RILUZOLE 50 MG TABLET [Rilutek] |
1 |
Tier 1 |
$0.00 | N/A | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | N/A | None |
RISEDRONATE SOD DR 35 MG TABLET DR [Atelvia] |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
RISEDRONATE SODIUM 150 MG TAB [Actonel] |
1 |
Tier 1 |
$0.00 | N/A | Q:1 /30Days |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RISEDRONATE SODIUM 35 MG TAB [Actonel] |
1 |
Tier 1 |
$0.00 | N/A | Q:4 /28Days |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RISPERDAL CONSTA 25MG SYR |
1 |
Tier 1 |
$0.00 | N/A | P Q:4 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
1 |
Tier 1 |
$0.00 | N/A | P Q:4 /28Days |
RISPERDAL CONSTA 50MG SYR |
1 |
Tier 1 |
$0.00 | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
1 |
Tier 1 |
$0.00 | N/A | P Q:4 /28Days |
RISPERIDONE 0.25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RISPERIDONE 0.5 MG ODT |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RISPERIDONE 0.5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RISPERIDONE 1 MG ODT |
1 |
Tier 1 |
$0.00 | N/A | Q:120 /30Days |
RISPERIDONE 1 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:120 /30Days |
RISPERIDONE 1 MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | N/A | Q:480 /30Days |
RISPERIDONE 2 MG ODT |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RISPERIDONE 2 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RISPERIDONE 3 MG ODT |
1 |
Tier 1 |
$0.00 | N/A | Q:150 /30Days |
RISPERIDONE 3 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 4 MG ODT |
1 |
Tier 1 |
$0.00 | N/A | Q:120 /30Days |
RISPERIDONE 4 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:120 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RITONAVIR 100 MG TABLET [Norvir] |
1 |
Tier 1 |
$0.00 | N/A | None |
RITUXAN 10 MG/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
RITUXAN 10MG/ML VIAL |
1 |
Tier 1 |
$0.00 | N/A | P |
RIVASTIGMINE 1.5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RIVASTIGMINE 13.3 MG/24HR PTCH |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RIVASTIGMINE 3 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RIVASTIGMINE 4.5 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RIVASTIGMINE 4.6 MG/24HR PATCH |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 6 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | Q:60 /30Days |
RIVASTIGMINE 9.5 MG/24HR PATCH |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
RIZATRIPTAN 10 MG TABLET [Maxalt-MLT] |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
RIZATRIPTAN 5 MG ODT [Maxalt-MLT] |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
RIZATRIPTAN 5 MG TABLET [Maxalt-MLT] |
1 |
Tier 1 |
$0.00 | N/A | Q:18 /30Days |
ROPINIROLE HCL 0.25 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL 0.5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL 1 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL 2 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL 3 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL 4 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL 5 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL ER 12 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL ER 2 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL ER 4 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL ER 6 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROPINIROLE HCL ER 8 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | None |
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor] |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROTARIX VACCINE SUSPENSION |
1 |
Tier 1 |
$0.00 | N/A | None |
ROTATEQ VACCINE Solution |
1 |
Tier 1 |
$0.00 | N/A | None |
Roweepra 1,000 mg tablet |
1 |
Tier 1 |
$0.00 | N/A | None |
Roweepra 500 mg tablet |
1 |
Tier 1 |
$0.00 | N/A | None |
Roweepra 750 mg tablet |
1 |
Tier 1 |
$0.00 | N/A | None |
ROWEEPRA XR 500 MG TABLET ER 24H |
1 |
Tier 1 |
$0.00 | N/A | None |
ROWEEPRA XR 750 MG TABLET ER 24H |
1 |
Tier 1 |
$0.00 | N/A | None |
ROZEREM 8 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
RUBRACA 200 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
RUBRACA 250 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
RUBRACA 300 MG TABLET |
1 |
Tier 1 |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RYDAPT 25 MG CAPSULE |
1 |
Tier 1 |
$0.00 | N/A | P |