Q1Medicare.com 2018 Medicare Part D or Medicare Advantage Plan Formulary Browser

2018 Medicare Part D Plan Formulary Information
Blue MedicareRx Value Plus (PDP) (S2893-001-0) Benefit Details
The Blue MedicareRx Value Plus (PDP) (S2893-001-0) Formulary Drugs Starting with the Letter R in CMS PDP Region 2 which includes: CT MA RI VT Plan Monthly Premium: $38.20 Deductible: $235 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
RABAVERT RABIES VACCINE VIAL	3	Preferred Brand	$35.00	N/A	None
RALOXIFENE HCL 60 MG TABLET [Evista]	3	Preferred Brand	$35.00	N/A	None
RAMIPRIL 1.25 MG CAPSULE	1*	Preferred Generic	$2.00	N/A	None
RAMIPRIL 10 MG CAPSULE	1*	Preferred Generic	$2.00	N/A	None
RAMIPRIL 2.5 MG CAPSULE	1*	Preferred Generic	$2.00	N/A	None
RAMIPRIL 5 MG CAPSULE	1*	Preferred Generic	$2.00	N/A	None
RANEXA ER 1,000 MG TABLET	4	Non-Preferred Drug	40%	N/A	None
RANEXA ER 500 MG TABLET	4	Non-Preferred Drug	40%	N/A	None
RANITIDINE 15 MG/ML SYRUP	3	Preferred Brand	$35.00	N/A	None
RANITIDINE 150 MG TABLET	1*	Preferred Generic	$2.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE 300 MG TABLET	1*	Preferred Generic	$2.00	N/A	None
RANITIDINE HCL 50 MG/2 ML VIAL	4	Non-Preferred Drug	40%	N/A	None
RAPAMUNE 1MG/ML ORAL TUBEX	5	Specialty Tier	28%	N/A	P
Rasagiline Mesylate 0.5 MG TABLET [Azilect]	4	Non-Preferred Drug	40%	N/A	None
Rasagiline Mesylate 1 MG TABLET [Azilect]	4	Non-Preferred Drug	40%	N/A	None
RAYALDEE ER 30 MCG CAPSULE	5	Specialty Tier	28%	N/A	None
RECLIPSEN 28 DAY TABLET [Solia]	3	Preferred Brand	$35.00	N/A	None
RECOMBIVAX HB 10 MCG/ML SYR	3	Preferred Brand	$35.00	N/A	P
RECOMBIVAX HB 40MCG/ML VIAL	3	Preferred Brand	$35.00	N/A	P
REGRANEX 0.01% GEL	5	Specialty Tier	28%	N/A	P
RELENZA 5MG DISKHALER	3	Preferred Brand	$35.00	N/A	Q:120 /365Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RELISTOR 12 MG/0.6 ML SYRINGE	5	Specialty Tier	28%	N/A	P
RELISTOR 12 MG/0.6 ML VIAL	5	Specialty Tier	28%	N/A	P
RELISTOR 8 MG/0.4 ML SYRINGE	5	Specialty Tier	28%	N/A	P
REMICADE 100MG VIAL	5	Specialty Tier	28%	N/A	P
REMODULIN 10MG/ML VIAL	5	Specialty Tier	28%	N/A	P
REMODULIN 1MG/ML VIAL	5	Specialty Tier	28%	N/A	P
REMODULIN 2.5MG/ML VIAL	5	Specialty Tier	28%	N/A	P
REMODULIN 5MG/ML VIAL	5	Specialty Tier	28%	N/A	P
REPAGLINIDE 0.5 MG TABLET [Prandin]	2*	Generic	$7.00	N/A	Q:120 /30Days
REPAGLINIDE 1 MG TABLET [Prandin]	2*	Generic	$7.00	N/A	Q:120 /30Days
REPAGLINIDE 2 MG TABLET [Prandin]	2*	Generic	$7.00	N/A	Q:240 /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	40%	N/A	None
RESCRIPTOR 200 MG TABLET	4	Non-Preferred Drug	40%	N/A	None
RESTASIS 0.05% EYE EMULSION	3	Preferred Brand	$35.00	N/A	Q:64 /30Days
RETROVIR 200 MG/20 ML VIAL	4	Non-Preferred Drug	40%	N/A	None
REVLIMID 10 MG CAPSULE	5	Specialty Tier	28%	N/A	P Q:28 /28Days
REVLIMID 15MG CAPSULE 21 BOT	5	Specialty Tier	28%	N/A	P Q:28 /28Days
REVLIMID 2.5 MG CAPSULE	5	Specialty Tier	28%	N/A	P Q:28 /28Days
REVLIMID 20 MG CAPSULE	5	Specialty Tier	28%	N/A	P Q:28 /28Days
REVLIMID 25 MG CAPSULE	5	Specialty Tier	28%	N/A	P Q:28 /28Days
REVLIMID 5 MG CAPSULE	5	Specialty Tier	28%	N/A	P Q:28 /28Days
REXULTI 0.25 MG TABLET	4	Non-Preferred Drug	40%	N/A	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REXULTI 0.5 MG TABLET	4	Non-Preferred Drug	40%	N/A	Q:180 /30Days
REXULTI 1 MG TABLET	4	Non-Preferred Drug	40%	N/A	Q:90 /30Days
REXULTI 2 MG TABLET	4	Non-Preferred Drug	40%	N/A	Q:60 /30Days
REXULTI 3 MG TABLET	4	Non-Preferred Drug	40%	N/A	Q:30 /30Days
REXULTI 4 MG TABLET	4	Non-Preferred Drug	40%	N/A	Q:30 /30Days
REYATAZ 50 MG POWDER PACKET	5	Specialty Tier	28%	N/A	None
RIBASPHERE 200 MG CAPSULE	3	Preferred Brand	$35.00	N/A	None
RIBASPHERE 200MG TABLET	4	Non-Preferred Drug	40%	N/A	None
RIBAVIRIN 200 MG CAPSULE	3	Preferred Brand	$35.00	N/A	None
RIBAVIRIN 200MG TABLET 168 BOT	4	Non-Preferred Drug	40%	N/A	None
RIFABUTIN 150 MG CAPSULE [Mycobutin]	4	Non-Preferred Drug	40%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIFAMPIN 150 MG CAPSULE	3	Preferred Brand	$35.00	N/A	None
RIFAMPIN 300 MG CAPSULE	3	Preferred Brand	$35.00	N/A	None
RIFAMPIN IV 600 MG VIAL	4	Non-Preferred Drug	40%	N/A	None
RIFATER 50/300/120 TABLET	4	Non-Preferred Drug	40%	N/A	None
RILUZOLE 50 MG TABLET [Rilutek]	3	Preferred Brand	$35.00	N/A	None
Rimantadine 100mg/1 100 TABLET BOTTLE	3	Preferred Brand	$35.00	N/A	None
RISPERDAL CONSTA 25MG SYR	4	Non-Preferred Drug	40%	N/A	Q:2 /28Days
RISPERDAL CONSTA 37.5MG SYR	4	Non-Preferred Drug	40%	N/A	Q:2 /28Days
RISPERDAL CONSTA 50MG SYR	4	Non-Preferred Drug	40%	N/A	Q:2 /28Days
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	4	Non-Preferred Drug	40%	N/A	Q:2 /28Days
RISPERIDONE 0.25 MG TABLET	2*	Generic	$7.00	N/A	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE 0.5 MG ODT	4	Non-Preferred Drug	40%	N/A	Q:90 /30Days
RISPERIDONE 0.5 MG TABLET	2*	Generic	$7.00	N/A	Q:90 /30Days
RISPERIDONE 1 MG ODT	4	Non-Preferred Drug	40%	N/A	Q:60 /30Days
RISPERIDONE 1 MG TABLET	2*	Generic	$7.00	N/A	Q:60 /30Days
RISPERIDONE 1 MG/ML SOLUTION	3	Preferred Brand	$35.00	N/A	Q:240 /30Days
RISPERIDONE 2 MG ODT	4	Non-Preferred Drug	40%	N/A	Q:60 /30Days
RISPERIDONE 2 MG TABLET	2*	Generic	$7.00	N/A	Q:60 /30Days
RISPERIDONE 3 MG ODT	4	Non-Preferred Drug	40%	N/A	Q:60 /30Days
RISPERIDONE 3 MG TABLET	2*	Generic	$7.00	N/A	Q:60 /30Days
RISPERIDONE 4 MG ODT	4	Non-Preferred Drug	40%	N/A	Q:120 /30Days
RISPERIDONE 4 MG TABLET	2*	Generic	$7.00	N/A	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	4	Non-Preferred Drug	40%	N/A	Q:90 /30Days
RITONAVIR 100 MG TABLET [Norvir]	3	Preferred Brand	$35.00	N/A	None
RITUXAN 10 MG/ML VIAL	5	Specialty Tier	28%	N/A	P
RITUXAN 10MG/ML VIAL	5	Specialty Tier	28%	N/A	P
RIVASTIGMINE 1.5 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	None
RIVASTIGMINE 13.3 MG/24HR PTCH	4	Non-Preferred Drug	40%	N/A	Q:30 /30Days
RIVASTIGMINE 3 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	None
RIVASTIGMINE 4.5 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	None
RIVASTIGMINE 4.6 MG/24HR PATCH	4	Non-Preferred Drug	40%	N/A	Q:30 /30Days
RIVASTIGMINE 6 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	None
RIVASTIGMINE 9.5 MG/24HR PATCH	4	Non-Preferred Drug	40%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIZATRIPTAN 10 MG TABLET [Maxalt-MLT]	3	Preferred Brand	$35.00	N/A	Q:18 /30Days
RIZATRIPTAN 5 MG TABLET [Maxalt-MLT]	3	Preferred Brand	$35.00	N/A	Q:18 /30Days
ROPINIROLE HCL 0.25 MG TABLET	2*	Generic	$7.00	N/A	None
ROPINIROLE HCL 0.5 MG TABLET	2*	Generic	$7.00	N/A	None
ROPINIROLE HCL 1 MG TABLET	2*	Generic	$7.00	N/A	None
ROPINIROLE HCL 2 MG TABLET	2*	Generic	$7.00	N/A	None
ROPINIROLE HCL 3 MG TABLET	2*	Generic	$7.00	N/A	None
ROPINIROLE HCL 4 MG TABLET	2*	Generic	$7.00	N/A	None
ROPINIROLE HCL 5 MG TABLET	2*	Generic	$7.00	N/A	None
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor]	1*	Preferred Generic	$2.00	N/A	Q:30 /30Days
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor]	1*	Preferred Generic	$2.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor]	1*	Preferred Generic	$2.00	N/A	Q:30 /30Days
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor]	1*	Preferred Generic	$2.00	N/A	Q:30 /30Days
ROTARIX VACCINE SUSPENSION	3	Preferred Brand	$35.00	N/A	None
ROTATEQ VACCINE Solution	3	Preferred Brand	$35.00	N/A	None
Roweepra 1,000 mg tablet	3	Preferred Brand	$35.00	N/A	None
Roweepra 500 mg tablet	3	Preferred Brand	$35.00	N/A	None
Roweepra 750 mg tablet	3	Preferred Brand	$35.00	N/A	None
RUBRACA 200 MG TABLET	5	Specialty Tier	28%	N/A	P
RUBRACA 250 MG TABLET	5	Specialty Tier	28%	N/A	P
RUBRACA 300 MG TABLET	5	Specialty Tier	28%	N/A	P
RYDAPT 25 MG CAPSULE	5	Specialty Tier	28%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Blue MedicareRx 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.