2019 Medicare Part D Plan Formulary Information |
Nascentia Health Dual (HMO SNP) (H9066-003-0)
Benefit Details
|
The Nascentia Health Dual (HMO SNP) (H9066-003-0) Formulary Drugs Starting with the Letter R in Greene County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $39.30 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 |
1 |
All Formulary Drugs |
15% | 15% | P |
RALOXIFENE HCL 60 MG TABLET [Evista] |
1 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days |
RAMIPRIL 1.25 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RAMIPRIL 10 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RAMIPRIL 2.5 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RAMIPRIL 5 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RANITIDINE 15 MG/ML SYRUP |
1 |
All Formulary Drugs |
15% | 15% | None |
RANITIDINE 150 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RANITIDINE 150 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
RANITIDINE 300 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANITIDINE 300 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
RANOLAZINE ER 1,000 MG TABLET ER 12H [Ranexa] |
1 |
All Formulary Drugs |
15% | 15% | S |
RANOLAZINE ER 500 MG TABLET ER 12H [Ranexa] |
1 |
All Formulary Drugs |
15% | 15% | S |
Rasagiline Mesylate 0.5 MG TABLET [Azilect] |
1 |
All Formulary Drugs |
15% | 15% | None |
Rasagiline Mesylate 1 MG TABLET [Azilect] |
1 |
All Formulary Drugs |
15% | 15% | None |
RAVICTI 1.1 GRAM/ML LIQUID |
1 |
All Formulary Drugs |
15% | 15% | P |
RECLIPSEN 28 DAY TABLET [Solia] |
1 |
All Formulary Drugs |
15% | 15% | None |
RECOMBIVAX HB 10 MCG/ML SYR |
1 |
All Formulary Drugs |
15% | 15% | P |
RECOMBIVAX HB 40MCG/ML VIAL |
1 |
All Formulary Drugs |
15% | 15% | P |
RECTIV 0.4% OINTMENT |
1 |
All Formulary Drugs |
15% | 15% | None |
REGRANEX 0.01% GEL |
1 |
All Formulary Drugs |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELENZA 5MG DISKHALER |
1 |
All Formulary Drugs |
15% | 15% | None |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
1 |
All Formulary Drugs |
15% | 15% | None |
REPAGLINIDE 1 MG TABLET [Prandin] |
1 |
All Formulary Drugs |
15% | 15% | None |
REPAGLINIDE 2 MG TABLET [Prandin] |
1 |
All Formulary Drugs |
15% | 15% | None |
REPAGLINIDE-METFORMIN 1-500 MG [PrandiMet] |
1 |
All Formulary Drugs |
15% | 15% | None |
REPAGLINIDE-METFORMIN 2-500 MG [PrandiMet] |
1 |
All Formulary Drugs |
15% | 15% | None |
REPATHA 140 MG/ML SURECLICK |
1 |
All Formulary Drugs |
15% | 15% | P |
REPATHA 140 MG/ML SYRINGE |
1 |
All Formulary Drugs |
15% | 15% | P |
REPATHA 420 MG/3.5ML PUSHTRONX |
1 |
All Formulary Drugs |
15% | 15% | P |
RESCRIPTOR 200 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:180 /30Days |
RESTASIS 0.05% EYE EMULSION |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETACRIT 10,000 UNIT/ML VIAL |
1 |
All Formulary Drugs |
15% | 15% | P Q:12 /28Days |
RETACRIT 2,000 UNIT/ML VIAL |
1 |
All Formulary Drugs |
15% | 15% | P Q:23 /30Days |
RETACRIT 3,000 UNIT/ML VIAL |
1 |
All Formulary Drugs |
15% | 15% | P Q:16 /30Days |
RETACRIT 4,000 UNIT/ML VIAL |
1 |
All Formulary Drugs |
15% | 15% | P Q:12 /28Days |
RETACRIT 40,000 UNIT/ML VIAL |
1 |
All Formulary Drugs |
15% | 15% | P Q:12 /28Days |
REVLIMID 10 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | P Q:28 /28Days |
REVLIMID 15MG CAPSULE 21 BOT |
1 |
All Formulary Drugs |
15% | 15% | P Q:28 /28Days |
REVLIMID 2.5 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | P Q:28 /28Days |
REVLIMID 20 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | P Q:28 /28Days |
REVLIMID 25 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | P Q:28 /28Days |
REVLIMID 5 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 0.25 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
REXULTI 0.5 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
REXULTI 1 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
REXULTI 2 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
REXULTI 3 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
REXULTI 4 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
REYATAZ 50 MG POWDER PACKET |
1 |
All Formulary Drugs |
15% | 15% | Q:180 /30Days |
RIBASPHERE 200 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RIBAVIRIN 200 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RIBAVIRIN 200MG TABLET 168 BOT |
1 |
All Formulary Drugs |
15% | 15% | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
1 |
All Formulary Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIFAMPIN 150 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RIFAMPIN 300 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | None |
RIFAMPIN IV 600 MG VIAL |
1 |
All Formulary Drugs |
15% | 15% | P |
RIFATER 50/300/120 TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
RILUZOLE 50 MG TABLET [Rilutek] |
1 |
All Formulary Drugs |
15% | 15% | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
1 |
All Formulary Drugs |
15% | 15% | None |
RISEDRONATE SODIUM 150 MG TAB [Actonel] |
1 |
All Formulary Drugs |
15% | 15% | Q:1 /28Days |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
1 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days |
RISEDRONATE SODIUM 35 MG TAB [Actonel] |
1 |
All Formulary Drugs |
15% | 15% | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
1 |
All Formulary Drugs |
15% | 15% | Q:4 /28Days |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
1 |
All Formulary Drugs |
15% | 15% | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
1 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days |
RISPERDAL CONSTA 25MG SYR |
1 |
All Formulary Drugs |
15% | 15% | Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
1 |
All Formulary Drugs |
15% | 15% | Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
1 |
All Formulary Drugs |
15% | 15% | Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
1 |
All Formulary Drugs |
15% | 15% | Q:2 /28Days |
RISPERIDONE 0.25 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 0.5 MG ODT |
1 |
All Formulary Drugs |
15% | 15% | Q:120 /30Days |
RISPERIDONE 0.5 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:120 /30Days |
RISPERIDONE 1 MG ODT |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 1 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 1 MG/ML SOLUTION |
1 |
All Formulary Drugs |
15% | 15% | Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 2 MG ODT |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 2 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 3 MG ODT |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 3 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 4 MG ODT |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE 4 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RITONAVIR 100 MG TABLET [Norvir] |
1 |
All Formulary Drugs |
15% | 15% | Q:360 /30Days |
RIVASTIGMINE 1.5 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RIVASTIGMINE 13.3 MG/24HR PTCH |
1 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days |
RIVASTIGMINE 3 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIVASTIGMINE 4.5 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RIVASTIGMINE 4.6 MG/24HR PATCH |
1 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days |
RIVASTIGMINE 6 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days |
RIVASTIGMINE 9.5 MG/24HR PATCH |
1 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days |
RIZATRIPTAN 10 MG ODT [Maxalt-MLT] |
1 |
All Formulary Drugs |
15% | 15% | Q:12 /30Days |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
1 |
All Formulary Drugs |
15% | 15% | Q:12 /30Days |
RIZATRIPTAN 5 MG ODT [Maxalt-MLT] |
1 |
All Formulary Drugs |
15% | 15% | Q:24 /30Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
1 |
All Formulary Drugs |
15% | 15% | Q:24 /30Days |
ROPINIROLE HCL 0.25 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
ROPINIROLE HCL 0.5 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
ROPINIROLE HCL 1 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROPINIROLE HCL 2 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
ROPINIROLE HCL 3 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
ROPINIROLE HCL 4 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
ROPINIROLE HCL 5 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | None |
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor] |
1 |
All Formulary Drugs |
15% | 15% | None |
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor] |
1 |
All Formulary Drugs |
15% | 15% | None |
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor] |
1 |
All Formulary Drugs |
15% | 15% | None |
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor] |
1 |
All Formulary Drugs |
15% | 15% | None |
ROTARIX VACCINE SUSPENSION |
1 |
All Formulary Drugs |
15% | 15% | None |
ROTATEQ VACCINE Solution |
1 |
All Formulary Drugs |
15% | 15% | None |
Roweepra 1,000 mg tablet |
1 |
All Formulary Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Roweepra 750 mg tablet |
1 |
All Formulary Drugs |
15% | 15% | None |
ROWEEPRA XR 500 MG TABLET ER 24H |
1 |
All Formulary Drugs |
15% | 15% | None |
ROWEEPRA XR 750 MG TABLET ER 24H |
1 |
All Formulary Drugs |
15% | 15% | None |
RUBRACA 200 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | P |
RUBRACA 250 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | P |
RUBRACA 300 MG TABLET |
1 |
All Formulary Drugs |
15% | 15% | P |
RYDAPT 25 MG CAPSULE |
1 |
All Formulary Drugs |
15% | 15% | P Q:240 /30Days |
RYTARY ER 23.75 MG-95 MG CAP |
1 |
All Formulary Drugs |
15% | 15% | S |
RYTARY ER 36.25 MG-145 MG CAP |
1 |
All Formulary Drugs |
15% | 15% | S |
RYTARY ER 48.75 MG-195 MG CAP |
1 |
All Formulary Drugs |
15% | 15% | S |
RYTARY ER 61.25 MG-245 MG CAP |
1 |
All Formulary Drugs |
15% | 15% | S |