2019 Medicare Part D Plan Formulary Information |
UPMC for Life Dual (HMO SNP) (H4279-001-0)
Benefit Details
|
The UPMC for Life Dual (HMO SNP) (H4279-001-0) Formulary Drugs Starting with the Letter R in Philadelphia County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $37.00 Deductible: $415 |
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 |
$10.00 | $25.00 | None |
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex] |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days |
RALOXIFENE HCL 60 MG TABLET [Evista] |
4 |
Non-Preferred Drug |
46% | 46% | None |
RAMIPRIL 1.25 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
RAMIPRIL 10 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
RAMIPRIL 2.5 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
RAMIPRIL 5 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
RANITIDINE 15 MG/ML SYRUP |
4 |
Non-Preferred Drug |
46% | 46% | None |
RANITIDINE 150 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
RANITIDINE 300 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANOLAZINE ER 1,000 MG TABLET ER 12H [Ranexa] |
3 |
Preferred Brand |
$10.00 | $25.00 | Q:60 /30Days |
RANOLAZINE ER 500 MG TABLET ER 12H [Ranexa] |
3 |
Preferred Brand |
$10.00 | $25.00 | Q:60 /30Days |
Rasagiline Mesylate 0.5 MG TABLET [Azilect] |
4 |
Non-Preferred Drug |
46% | 46% | None |
Rasagiline Mesylate 1 MG TABLET [Azilect] |
4 |
Non-Preferred Drug |
46% | 46% | None |
RASUVO 10 MG/0.2 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:1 /28Days |
RASUVO 12.5 MG/0.25 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:1 /28Days |
RASUVO 15 MG/0.3 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:1 /28Days |
RASUVO 17.5 MG/0.35 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:1 /28Days |
RASUVO 20 MG/0.4 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:2 /28Days |
RASUVO 22.5 MG/0.45 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:2 /28Days |
RASUVO 25 MG/0.5 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RASUVO 30 MG/0.6 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:2 /28Days |
RASUVO 7.5 MG/0.15 ML AUTOINJ |
3 |
Preferred Brand |
$10.00 | $25.00 | P Q:1 /28Days |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
25% | N/A | P Q:525 /30Days |
RAYALDEE ER 30 MCG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
REBETOL 40MG/ML SOLUTION |
5 |
Specialty Tier |
25% | N/A | None |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | S Q:6 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | S Q:6 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | S Q:6 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | S Q:6 /28Days |
REBIF REBIDOSE TITRATION PACK |
5 |
Specialty Tier |
25% | N/A | S Q:8 /365Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
25% | N/A | S Q:8 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RECLIPSEN 28 DAY TABLET [Solia] |
2 |
Generic |
$6.00 | $12.00 | None |
RECOMBIVAX HB 10 MCG/ML SYR |
3 |
Preferred Brand |
$10.00 | $25.00 | P |
RECOMBIVAX HB 40MCG/ML VIAL |
3 |
Preferred Brand |
$10.00 | $25.00 | P |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
25% | N/A | P |
RELENZA 5MG DISKHALER |
3 |
Preferred Brand |
$10.00 | $25.00 | Q:120 /365Days |
RELISTOR 12 MG/0.6 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
RELISTOR 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
RELISTOR 8 MG/0.4 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
2 |
Generic |
$6.00 | $12.00 | None |
REPAGLINIDE 1 MG TABLET [Prandin] |
2 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REPAGLINIDE 2 MG TABLET [Prandin] |
2 |
Generic |
$6.00 | $12.00 | None |
REPATHA 140 MG/ML SURECLICK |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
REPATHA 140 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
REPATHA 420 MG/3.5ML PUSHTRONX |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
RESCRIPTOR 200 MG TABLET |
4 |
Non-Preferred Drug |
46% | 46% | None |
RESTASIS 0.05% EYE EMULSION |
3 |
Preferred Brand |
$10.00 | $25.00 | Q:60 /30Days |
RETACRIT 10,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
RETACRIT 2,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
RETACRIT 3,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
RETACRIT 4,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
RETACRIT 40,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REVATIO 10 MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
REVLIMID 10 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
REVLIMID 15MG CAPSULE 21 BOT |
5 |
Specialty Tier |
25% | N/A | P |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
REVLIMID 25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
REVLIMID 5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:480 /30Days |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
25% | 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 |
5 |
Specialty Tier |
25% | N/A | P Q:45 /30Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
REYATAZ 50 MG POWDER PACKET |
5 |
Specialty Tier |
25% | N/A | None |
RIBASPHERE 200 MG CAPSULE |
2 |
Generic |
$6.00 | $12.00 | None |
RIBASPHERE 600MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
RIBASPHERE RibaPak |
5 |
Specialty Tier |
25% | N/A | None |
RIBASPHERE RibaPak 600mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
RIBAVIRIN 200 MG CAPSULE |
2 |
Generic |
$6.00 | $12.00 | None |
RIBAVIRIN 200MG TABLET 168 BOT |
2 |
Generic |
$6.00 | $12.00 | None |
RIDAURA 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
4 |
Non-Preferred Drug |
46% | 46% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 150 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIFAMPIN 300 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIFAMPIN IV 600 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
RILUZOLE 50 MG TABLET [Rilutek] |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RISEDRONATE SOD DR 35 MG TABLET DR [Atelvia] |
4 |
Non-Preferred Drug |
46% | 46% | S Q:4 /28Days |
RISEDRONATE SODIUM 150 MG TAB [Actonel] |
4 |
Non-Preferred Drug |
46% | 46% | S Q:1 /28Days |
RISEDRONATE SODIUM 35 MG TAB [Actonel] |
4 |
Non-Preferred Drug |
46% | 46% | S Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Drug |
46% | 46% | S Q:12 /84Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
4 |
Non-Preferred Drug |
46% | 46% | S Q:4 /28Days |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Drug |
46% | 46% | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:4 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Drug |
46% | 46% | Q:8 /28Days |
RISPERIDONE 0.25 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | Q:1920 /30Days |
RISPERIDONE 0.5 MG ODT |
4 |
Non-Preferred Drug |
46% | 46% | S Q:960 /30Days |
RISPERIDONE 0.5 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | Q:960 /30Days |
RISPERIDONE 1 MG ODT |
4 |
Non-Preferred Drug |
46% | 46% | S Q:480 /30Days |
RISPERIDONE 1 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | Q:480 /30Days |
RISPERIDONE 1 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
46% | 46% | Q:480 /30Days |
RISPERIDONE 2 MG ODT |
4 |
Non-Preferred Drug |
46% | 46% | S Q:240 /30Days |
RISPERIDONE 2 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 3 MG ODT |
4 |
Non-Preferred Drug |
46% | 46% | S Q:180 /30Days |
RISPERIDONE 3 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | Q:180 /30Days |
RISPERIDONE 4 MG ODT |
4 |
Non-Preferred Drug |
46% | 46% | S Q:120 /30Days |
RISPERIDONE 4 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | Q:120 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
4 |
Non-Preferred Drug |
46% | 46% | S Q:1920 /30Days |
RITONAVIR 100 MG TABLET [Norvir] |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIVASTIGMINE 1.5 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIVASTIGMINE 13.3 MG/24HR PTCH |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIVASTIGMINE 3 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIVASTIGMINE 4.5 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIVASTIGMINE 4.6 MG/24HR PATCH |
4 |
Non-Preferred Drug |
46% | 46% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 6 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIVASTIGMINE 9.5 MG/24HR PATCH |
4 |
Non-Preferred Drug |
46% | 46% | None |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
2 |
Generic |
$6.00 | $12.00 | Q:12 /28Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
2 |
Generic |
$6.00 | $12.00 | Q:12 /28Days |
RIZATRIPTAN 5 MG ODT [Maxalt-MLT] |
2 |
Generic |
$6.00 | $12.00 | Q:24 /28Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
2 |
Generic |
$6.00 | $12.00 | Q:24 /28Days |
ROPINIROLE HCL 0.25 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
ROPINIROLE HCL 0.5 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
ROPINIROLE HCL 1 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
ROPINIROLE HCL 2 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
ROPINIROLE HCL 3 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL 4 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
ROPINIROLE HCL 5 MG TABLET |
2 |
Generic |
$6.00 | $12.00 | None |
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor] |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor] |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor] |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor] |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
ROTARIX VACCINE SUSPENSION |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
ROTATEQ VACCINE Solution |
3 |
Preferred Brand |
$10.00 | $25.00 | None |
Roweepra 1,000 mg tablet |
4 |
Non-Preferred Drug |
46% | 46% | None |
ROWEEPRA 500 MG TABLET |
4 |
Non-Preferred Drug |
46% | 46% | None |
Roweepra 750 mg tablet |
4 |
Non-Preferred Drug |
46% | 46% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROWEEPRA XR 500 MG TABLET ER 24H |
4 |
Non-Preferred Drug |
46% | 46% | None |
ROWEEPRA XR 750 MG TABLET ER 24H |
4 |
Non-Preferred Drug |
46% | 46% | None |
ROZEREM 8 MG TABLET |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
RUBRACA 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
RUCONEST 2,100 UNIT VIAL |
5 |
Specialty Tier |
25% | N/A | P |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |