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2018 Medicare Part D and Medicare Advantage Plan Formulary Browser
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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First Health Part D Value Plus (PDP) (S5768-134-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2825)
Tier 5 (720)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-134-0)
Benefit Details           
The First Health Part D Value Plus (PDP) (S5768-134-0)
Formulary Drugs Starting with the Letter R
in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $56.30 Deductible: $0 Qualifies for LIS: No
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   3 Preferred Brand $47.00$141.00None
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex]   4 Non-Preferred Drug 50%50%S
RALOXIFENE HCL 60 MG TABLET [Evista]   3 Preferred Brand $47.00$141.00None
RAMIPRIL 1.25 MG CAPSULE   1 Preferred Generic $1.00$3.00None
RAMIPRIL 10 MG CAPSULE   1 Preferred Generic $1.00$3.00None
RAMIPRIL 2.5 MG CAPSULE   1 Preferred Generic $1.00$3.00None
RAMIPRIL 5 MG CAPSULE   1 Preferred Generic $1.00$3.00None
RANEXA ER 1,000 MG TABLET   3 Preferred Brand $47.00$141.00None
RANEXA ER 500 MG TABLET   3 Preferred Brand $47.00$141.00None
RANITIDINE 15 MG/ML SYRUP   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RANITIDINE 150 MG CAPSULE   2 Generic $2.00$6.00None
RANITIDINE 150 MG TABLET   1 Preferred Generic $1.00$3.00None
RANITIDINE 300 MG CAPSULE   2 Generic $2.00$6.00None
RANITIDINE 300 MG TABLET   1 Preferred Generic $1.00$3.00None
RANITIDINE HCL 50 MG/2 ML VIAL   4 Non-Preferred Drug 50%50%None
RAPAFLO 8 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
RAPAFLO CAPSULES 4MG 30 BOT   4 Non-Preferred Drug 50%50%Q:30
/30Days
RAPAMUNE 0.5MG TABLETS   4 Non-Preferred Drug 50%50%P
RAPAMUNE 1MG TABLET   4 Non-Preferred Drug 50%50%P
RAPAMUNE 1MG/ML ORAL TUBEX   5 Specialty Tier 33%N/AP
RAPAMUNE 2MG TABLET   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Rasagiline Mesylate 0.5 MG TABLET [Azilect]   4 Non-Preferred Drug 50%50%None
Rasagiline Mesylate 1 MG TABLET [Azilect]   4 Non-Preferred Drug 50%50%None
RASUVO 10 MG/0.2 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 12.5 MG/0.25 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 15 MG/0.3 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 17.5 MG/0.35 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 20 MG/0.4 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 22.5 MG/0.45 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 25 MG/0.5 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 30 MG/0.6 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
RASUVO 7.5 MG/0.15 ML AUTOINJ   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RAVICTI 1.1 GRAM/ML LIQUID   5 Specialty Tier 33%N/AP
RAYOS DR 1 MG TABLET   5 Specialty Tier 33%N/ANone
RAYOS DR 2 MG TABLET   5 Specialty Tier 33%N/ANone
RAYOS DR 5 MG TABLET   5 Specialty Tier 33%N/ANone
RAZADYNE 12MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
RAZADYNE 4MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
RAZADYNE 8MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
RAZADYNE ER 16MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
RAZADYNE ER 24MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
RAZADYNE ER 8MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
REBETOL 40MG/ML SOLUTION   5 Specialty Tier 33%N/ANone
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/AP Q:6
/28Days
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS   5 Specialty Tier 33%N/AP Q:6
/28Days
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL   5 Specialty Tier 33%N/AP Q:8
/365Days
RECLAST 5MG/100ML INJECTION   4 Non-Preferred Drug 50%50%None
RECLIPSEN 28 DAY TABLET [Solia]   3 Preferred Brand $47.00$141.00None
RECOMBIVAX HB 10 MCG/ML SYR   3 Preferred Brand $47.00$141.00P
RECOMBIVAX HB 40MCG/ML VIAL   3 Preferred Brand $47.00$141.00P
RECTIV 0.4% OINTMENT   4 Non-Preferred Drug 50%50%None
REGRANEX 0.01% GEL   5 Specialty Tier 33%N/AP
RELENZA 5MG DISKHALER   3 Preferred Brand $47.00$141.00None
RELISTOR 12 MG/0.6 ML SYRINGE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RELISTOR 12 MG/0.6 ML VIAL   5 Specialty Tier 33%N/AP
RELISTOR 8 MG/0.4 ML SYRINGE   5 Specialty Tier 33%N/AP
RELPAX 20MG TABLET   3 Preferred Brand $47.00$141.00Q:12
/30Days
RELPAX 40 MG TABLET   3 Preferred Brand $47.00$141.00Q:12
/30Days
REMERON 15MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
REMERON 30MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN   4 Non-Preferred Drug 50%50%Q:30
/30Days
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN   4 Non-Preferred Drug 50%50%Q:30
/30Days
REMERON SLTABLET 45MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
REMICADE 100MG VIAL   5 Specialty Tier 33%N/AP
REMODULIN 10MG/ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
REMODULIN 1MG/ML VIAL   5 Specialty Tier 33%N/AP
REMODULIN 2.5MG/ML VIAL   5 Specialty Tier 33%N/AP
REMODULIN 5MG/ML VIAL   5 Specialty Tier 33%N/AP
RENAGEL 800MG TABLET   4 Non-Preferred Drug 50%50%S
RENVELA 800MG TABLET   3 Preferred Brand $47.00$141.00None
REPAGLINIDE 0.5 MG TABLET [Prandin]   2 Generic $2.00$6.00Q:120
/30Days
REPAGLINIDE 1 MG TABLET [Prandin]   2 Generic $2.00$6.00Q:120
/30Days
REPAGLINIDE 2 MG TABLET [Prandin]   2 Generic $2.00$6.00Q:240
/30Days
REPAGLINIDE-METFORMIN 1-500 MG [PrandiMet]   2 Generic $2.00$6.00Q:150
/30Days
REPAGLINIDE-METFORMIN 2-500 MG [PrandiMet]   2 Generic $2.00$6.00Q:150
/30Days
REQUIP 0.25 MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
REQUIP 0.5MG TABLET   4 Non-Preferred Drug 50%50%None
REQUIP 1MG TABLET   4 Non-Preferred Drug 50%50%None
REQUIP 2MG TABLET   4 Non-Preferred Drug 50%50%None
REQUIP 3MG TABLET   4 Non-Preferred Drug 50%50%None
REQUIP 4MG TABLET   4 Non-Preferred Drug 50%50%None
REQUIP 5MG TABLET   4 Non-Preferred Drug 50%50%None
REQUIP XL 2 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%Q:30
/30Days
REQUIP XL 4 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%Q:150
/30Days
REQUIP XL 6 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%Q:120
/30Days
REQUIP XL 8 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%Q:90
/30Days
REQUIP XL TABLET 12 MG   4 Non-Preferred Drug 50%50%Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RESCRIPTOR 100mg/1 360 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
RESCRIPTOR 200 MG TABLET   4 Non-Preferred Drug 50%50%None
RESTASIS 0.05% EYE EMULSION   3 Preferred Brand $47.00$141.00Q:64
/30Days
RESTORIL 15mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%Q:30
/30Days
RESTORIL 22.5mg/1 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%Q:30
/30Days
RESTORIL 30mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%Q:30
/30Days
RESTORIL 7.5 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
RETIN-A 0.01% GEL   4 Non-Preferred Drug 50%50%P
RETIN-A 0.025% GEL   4 Non-Preferred Drug 50%50%P
RETIN-A MICRO 0.04% GEL   4 Non-Preferred Drug 50%50%P
RETIN-A MICRO 0.1% GEL   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RETIN-A MICRO PUMP 0.06% GEL   4 Non-Preferred Drug 50%50%P
RETIN-A MICRO PUMP 0.08% GEL   4 Non-Preferred Drug 50%50%P
RETROVIR 100mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
RETROVIR 200 MG/20 ML VIAL   3 Preferred Brand $47.00$141.00None
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
REVATIO 0.8 MG/ML 12.5 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%N/AP Q:1125
/30Days
REVATIO 10 MG/ML ORAL SUSP   5 Specialty Tier 33%N/AP Q:224
/30Days
REVATIO 20MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
REVLIMID 10 MG CAPSULE   5 Specialty Tier 33%N/AP
REVLIMID 15MG CAPSULE 21 BOT   5 Specialty Tier 33%N/AP
REVLIMID 2.5 MG CAPSULE   5 Specialty Tier 33%N/AP
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/AP
REVLIMID 25 MG CAPSULE   5 Specialty Tier 33%N/AP
REVLIMID 5 MG CAPSULE   5 Specialty Tier 33%N/AP
REXULTI 0.25 MG TABLET   5 Specialty Tier 33%N/AQ:360
/30Days
REXULTI 0.5 MG TABLET   5 Specialty Tier 33%N/AQ:180
/30Days
REXULTI 1 MG TABLET   5 Specialty Tier 33%N/AQ:90
/30Days
REXULTI 2 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
REXULTI 3 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
REXULTI 4 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
REYATAZ 150MG CAPSULE   5 Specialty Tier 33%N/ANone
REYATAZ 200MG CAPSULE   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
REYATAZ 300MG CAPSULE   5 Specialty Tier 33%N/ANone
REYATAZ 50 MG POWDER PACKET   5 Specialty Tier 33%N/ANone
RIBASPHERE 200 MG CAPSULE   3 Preferred Brand $47.00$141.00None
RIBASPHERE 200MG TABLET   3 Preferred Brand $47.00$141.00None
RIBASPHERE 400MG TABLET   4 Non-Preferred Drug 50%50%None
RIBASPHERE 600MG TABLET   4 Non-Preferred Drug 50%50%None
RIBASPHERE RibaPak   4 Non-Preferred Drug 50%50%None
Ribasphere RibaPak 200-400 mg   4 Non-Preferred Drug 50%50%None
RIBASPHERE RibaPak 400mg/1   4 Non-Preferred Drug 50%50%None
RIBASPHERE RibaPak 600mg/1   4 Non-Preferred Drug 50%50%None
RIBAVIRIN 200 MG CAPSULE   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RIBAVIRIN 200MG TABLET 168 BOT   3 Preferred Brand $47.00$141.00None
RIDAURA 3 MG CAPSULE   5 Specialty Tier 33%N/ANone
RIFABUTIN 150 MG CAPSULE [Mycobutin]   4 Non-Preferred Drug 50%50%None
RIFADIN 150MG CAPSULE   4 Non-Preferred Drug 50%50%None
RIFAMPIN 150 MG CAPSULE   3 Preferred Brand $47.00$141.00None
RIFAMPIN 300 MG CAPSULE   3 Preferred Brand $47.00$141.00None
RIFAMPIN IV 600 MG VIAL   4 Non-Preferred Drug 50%50%None
RIFATER 50/300/120 TABLET   4 Non-Preferred Drug 50%50%None
RILUTEK 50 MG TABLET   5 Specialty Tier 33%N/ANone
RILUZOLE 50 MG TABLET [Rilutek]   4 Non-Preferred Drug 50%50%None
Rimantadine 100mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RIOMET 500MG/5ML SOLUTION ORAL   4 Non-Preferred Drug 50%50%None
RISEDRONATE SOD DR 35 MG TABLET DR [Atelvia]   4 Non-Preferred Drug 50%50%Q:4
/28Days
RISEDRONATE SODIUM 150 MG TAB [Actonel]   4 Non-Preferred Drug 50%50%Q:1
/28Days
RISEDRONATE SODIUM 30 MG TABLET [Actonel]   4 Non-Preferred Drug 50%50%Q:30
/30Days
RISEDRONATE SODIUM 35 MG TAB [Actonel]   4 Non-Preferred Drug 50%50%Q:12
/84Days
RISEDRONATE SODIUM 35 MG TABLET [Actonel]   4 Non-Preferred Drug 50%50%Q:12
/84Days
RISEDRONATE SODIUM 35 MG TABLET [Actonel]   4 Non-Preferred Drug 50%50%Q:12
/84Days
RISEDRONATE SODIUM 5 MG TABLET [Actonel]   4 Non-Preferred Drug 50%50%Q:30
/30Days
RISPERDAL 0.25 MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
RISPERDAL 0.5 MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
RISPERDAL 1 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RISPERDAL 1MG/ML SOLUTION   4 Non-Preferred Drug 50%50%None
RISPERDAL 2 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
RISPERDAL 3 MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
RISPERDAL 4 MG TABLET   4 Non-Preferred Drug 50%50%Q:120
/30Days
RISPERDAL CONSTA 25MG SYR   4 Non-Preferred Drug 50%50%Q:2
/28Days
RISPERDAL CONSTA 37.5MG SYR   5 Specialty Tier 33%N/AQ:2
/28Days
RISPERDAL CONSTA 50MG SYR   5 Specialty Tier 33%N/AQ:2
/28Days
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL   4 Non-Preferred Drug 50%50%Q:2
/28Days
RISPERIDONE 0.25 MG TABLET   3 Preferred Brand $47.00$141.00Q:90
/30Days
RISPERIDONE 0.5 MG ODT   4 Non-Preferred Drug 50%50%Q:90
/30Days
RISPERIDONE 0.5 MG TABLET   3 Preferred Brand $47.00$141.00Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RISPERIDONE 1 MG ODT   4 Non-Preferred Drug 50%50%Q:60
/30Days
RISPERIDONE 1 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
RISPERIDONE 1 MG/ML SOLUTION   3 Preferred Brand $47.00$141.00None
RISPERIDONE 2 MG ODT   4 Non-Preferred Drug 50%50%Q:60
/30Days
RISPERIDONE 2 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
RISPERIDONE 3 MG ODT   4 Non-Preferred Drug 50%50%Q:90
/30Days
RISPERIDONE 3 MG TABLET   3 Preferred Brand $47.00$141.00Q:90
/30Days
RISPERIDONE 4 MG ODT   4 Non-Preferred Drug 50%50%Q:120
/30Days
RISPERIDONE 4 MG TABLET   3 Preferred Brand $47.00$141.00Q:120
/30Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK   4 Non-Preferred Drug 50%50%Q:90
/30Days
RITALIN 10MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RITALIN 20MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
RITALIN 5MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
RITALIN LA 10MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
RITALIN LA 20MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
RITALIN LA 30MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:60
/30Days
RITALIN LA 40MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
RITONAVIR 100 MG TABLET [Norvir]   3 Preferred Brand $47.00$141.00None
RITUXAN 10 MG/ML VIAL   5 Specialty Tier 33%N/AP
RITUXAN 10MG/ML VIAL   5 Specialty Tier 33%N/AP
RIVASTIGMINE 1.5 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
RIVASTIGMINE 13.3 MG/24HR PTCH   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RIVASTIGMINE 3 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
RIVASTIGMINE 4.5 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
RIVASTIGMINE 4.6 MG/24HR PATCH   4 Non-Preferred Drug 50%50%Q:30
/30Days
RIVASTIGMINE 6 MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
RIVASTIGMINE 9.5 MG/24HR PATCH   4 Non-Preferred Drug 50%50%Q:30
/30Days
RIVELSA TABLET TBDSPK 3MO   3 Preferred Brand $47.00$141.00None
RIZATRIPTAN 10 MG ODT [Maxalt-MLT]   3 Preferred Brand $47.00$141.00Q:12
/30Days
RIZATRIPTAN 10 MG TABLET [Maxalt-MLT]   3 Preferred Brand $47.00$141.00Q:12
/30Days
RIZATRIPTAN 5 MG ODT [Maxalt-MLT]   3 Preferred Brand $47.00$141.00Q:12
/30Days
RIZATRIPTAN 5 MG TABLET [Maxalt-MLT]   3 Preferred Brand $47.00$141.00Q:12
/30Days
ROBINUL 1MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ROBINUL FORTE 2MG TABLET   4 Non-Preferred Drug 50%50%None
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
ROPINIROLE HCL 0.25 MG TABLET   2 Generic $2.00$6.00None
ROPINIROLE HCL 0.5 MG TABLET   2 Generic $2.00$6.00None
ROPINIROLE HCL 1 MG TABLET   2 Generic $2.00$6.00None
ROPINIROLE HCL 2 MG TABLET   2 Generic $2.00$6.00None
ROPINIROLE HCL 3 MG TABLET   2 Generic $2.00$6.00None
ROPINIROLE HCL 4 MG TABLET   2 Generic $2.00$6.00None
ROPINIROLE HCL 5 MG TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ROPINIROLE HCL ER 12 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ROPINIROLE HCL ER 2 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ROPINIROLE HCL ER 4 MG TABLET   4 Non-Preferred Drug 50%50%Q:150
/30Days
ROPINIROLE HCL ER 6 MG TABLET   4 Non-Preferred Drug 50%50%Q:120
/30Days
ROPINIROLE HCL ER 8 MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor]   3 Preferred Brand $47.00$141.00Q:30
/30Days
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor]   3 Preferred Brand $47.00$141.00Q:30
/30Days
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor]   3 Preferred Brand $47.00$141.00Q:30
/30Days
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor]   3 Preferred Brand $47.00$141.00Q:30
/30Days
ROTARIX VACCINE SUSPENSION   3 Preferred Brand $47.00$141.00None
ROTATEQ VACCINE Solution   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Roweepra 1,000 mg tablet   2 Generic $2.00$6.00None
Roweepra 500 mg tablet   2 Generic $2.00$6.00None
Roweepra 750 mg tablet   2 Generic $2.00$6.00None
ROWEEPRA XR 500 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%None
ROWEEPRA XR 750 MG TABLET ER 24H   4 Non-Preferred Drug 50%50%None
ROXICODONE 15 MG TABLET   4 Non-Preferred Drug 50%50%Q:180
/30Days
ROXICODONE 30 MG TABLET   4 Non-Preferred Drug 50%50%Q:120
/30Days
ROXICODONE 5 MG TABLET   4 Non-Preferred Drug 50%50%Q:180
/30Days
ROZEREM 8 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
RUBRACA 200 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
RUBRACA 250 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
RUBRACA 300 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
RYDAPT 25 MG CAPSULE   5 Specialty Tier 33%N/AP
RYTARY ER 23.75 MG-95 MG CAP   4 Non-Preferred Drug 50%50%None
RYTARY ER 36.25 MG-145 MG CAP   4 Non-Preferred Drug 50%50%None
RYTARY ER 48.75 MG-195 MG CAP   4 Non-Preferred Drug 50%50%None
RYTARY ER 61.25 MG-245 MG CAP   4 Non-Preferred Drug 50%50%None
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Value Plus (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2018 )

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.





 
 


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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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