Q1Medicare.com 2019 Medicare Part D or Medicare Advantage Plan Formulary Browser

2019 Medicare Part D Plan Formulary Information
Senior Advantage Medicare Medicaid Plan (HMO SNP) (H1170-008-0) Benefit Details
The Senior Advantage Medicare Medicaid Plan (HMO SNP) (H1170-008-0) Formulary Drugs Starting with the Letter R in Clayton County, GA: CMS MA Region 8 which includes: GA Plan Monthly Premium: $23.10 Deductible: $0
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	6	Vaccines	$0.00	N/A	None
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex]	2	Generic	$15.00	$30.00	None
RALOXIFENE HCL 60 MG TABLET [Evista]	2	Generic	$15.00	$30.00	None
RAMIPRIL 1.25 MG CAPSULE	2	Generic	$15.00	$30.00	None
RAMIPRIL 10 MG CAPSULE	2	Generic	$15.00	$30.00	None
RAMIPRIL 2.5 MG CAPSULE	2	Generic	$15.00	$30.00	None
RAMIPRIL 5 MG CAPSULE	2	Generic	$15.00	$30.00	None
RANEXA ER 1,000 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RANEXA ER 500 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RANITIDINE 15 MG/ML SYRUP	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE 150 MG CAPSULE	2	Generic	$15.00	$30.00	None
RANITIDINE 150 MG TABLET	2	Generic	$15.00	$30.00	None
RANITIDINE 300 MG CAPSULE	2	Generic	$15.00	$30.00	None
RANITIDINE 300 MG TABLET	2	Generic	$15.00	$30.00	None
RANOLAZINE ER 1,000 MG TABLET ER 12H [Ranexa]	2	Generic	$15.00	$30.00	None
RANOLAZINE ER 500 MG TABLET ER 12H [Ranexa]	2	Generic	$15.00	$30.00	None
RAPAFLO 4 MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
RAPAFLO 8 MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
RAPAMUNE 0.5MG TABLETS	4	Non-Preferred Brand	$100.00	$200.00	P
RAPAMUNE 1MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	P
RAPAMUNE 1MG/ML ORAL TUBEX	4	Non-Preferred Brand	$100.00	$200.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RAPAMUNE 2MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	P
Rasagiline Mesylate 0.5 MG TABLET [Azilect]	2	Generic	$15.00	$30.00	None
Rasagiline Mesylate 1 MG TABLET [Azilect]	2	Generic	$15.00	$30.00	None
RASUVO 10 MG/0.2 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 12.5 MG/0.25 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 15 MG/0.3 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 17.5 MG/0.35 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 20 MG/0.4 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 22.5 MG/0.45 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 25 MG/0.5 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RASUVO 30 MG/0.6 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RASUVO 7.5 MG/0.15 ML AUTOINJ	3	Preferred Brand	$45.00	$90.00	None
RAVICTI 1.1 GRAM/ML LIQUID	5	Specialty Tier	33%	33%	None
RAYALDEE ER 30 MCG CAPSULE	5	Specialty Tier	33%	33%	None
RAYOS DR 1 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	P
RAYOS DR 2 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	P
RAYOS DR 5 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	P
RAZADYNE 12MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RAZADYNE 4MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RAZADYNE 8MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RAZADYNE ER 16MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
RAZADYNE ER 24MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RAZADYNE ER 8MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
REBETOL 40MG/ML SOLUTION	4	Non-Preferred Brand	$100.00	$200.00	None
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS	5	Specialty Tier	33%	33%	None
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS	5	Specialty Tier	33%	33%	None
REBIF REBIDOSE 22 MCG/0.5 ML	5	Specialty Tier	33%	33%	None
REBIF REBIDOSE 44 MCG/0.5 ML	5	Specialty Tier	33%	33%	None
REBIF REBIDOSE TITRATION PACK	5	Specialty Tier	33%	33%	None
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL	5	Specialty Tier	33%	33%	None
RECLIPSEN 28 DAY TABLET [Solia]	2	Generic	$15.00	$30.00	None
RECOMBIVAX HB 10 MCG/ML SYR	6	Vaccines	$0.00	N/A	P
RECOMBIVAX HB 40MCG/ML VIAL	6	Vaccines	$0.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RECTIV 0.4% OINTMENT	4	Non-Preferred Brand	$100.00	$200.00	None
REGRANEX 0.01% GEL	5	Specialty Tier	33%	33%	None
RELENZA 5MG DISKHALER	3	Preferred Brand	$45.00	$90.00	None
RELEXXII ER 72 MG TABLET ER 24	2	Generic	$15.00	$30.00	None
RELISTOR 12 MG/0.6 ML SYRINGE	5	Specialty Tier	33%	33%	None
RELISTOR 12 MG/0.6 ML VIAL	5	Specialty Tier	33%	33%	None
RELISTOR 150 MG TABLET	5	Specialty Tier	33%	33%	None
RELISTOR 8 MG/0.4 ML SYRINGE	5	Specialty Tier	33%	33%	None
RELPAX 20MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RELPAX 40 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REMERON 15MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REMERON 30MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN	4	Non-Preferred Brand	$100.00	$200.00	None
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN	4	Non-Preferred Brand	$100.00	$200.00	None
REMERON SLTABLET 45MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RENAGEL 800MG TABLET	3	Preferred Brand	$45.00	$90.00	None
RENVELA 800MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REPAGLINIDE 0.5 MG TABLET [Prandin]	2	Generic	$15.00	$30.00	None
REPAGLINIDE 1 MG TABLET [Prandin]	2	Generic	$15.00	$30.00	None
REPAGLINIDE 2 MG TABLET [Prandin]	2	Generic	$15.00	$30.00	None
REPAGLINIDE-METFORMIN 1-500 MG [PrandiMet]	2	Generic	$15.00	$30.00	None
REPAGLINIDE-METFORMIN 2-500 MG [PrandiMet]	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REPATHA 140 MG/ML SURECLICK	4	Non-Preferred Brand	$100.00	$200.00	P
REPATHA 140 MG/ML SYRINGE	4	Non-Preferred Brand	$100.00	$200.00	P
REPATHA 420 MG/3.5ML PUSHTRONX	4	Non-Preferred Brand	$100.00	$200.00	P
REQUIP XL 4 MG TABLET ER 24H	4	Non-Preferred Brand	$100.00	$200.00	None
REQUIP XL 8 MG TABLET ER 24H	4	Non-Preferred Brand	$100.00	$200.00	None
RESCRIPTOR 200 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
RESTASIS 0.05% EYE EMULSION	3	Preferred Brand	$45.00	$90.00	None
RESTORIL 15mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RESTORIL 22.5mg/1 30 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RESTORIL 30mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RESTORIL 7.5 MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RETACRIT 10,000 UNIT/ML VIAL	4	Non-Preferred Brand	$100.00	$200.00	P
RETACRIT 2,000 UNIT/ML VIAL	4	Non-Preferred Brand	$100.00	$200.00	P
RETACRIT 3,000 UNIT/ML VIAL	4	Non-Preferred Brand	$100.00	$200.00	P
RETACRIT 4,000 UNIT/ML VIAL	4	Non-Preferred Brand	$100.00	$200.00	P
RETACRIT 40,000 UNIT/ML VIAL	4	Non-Preferred Brand	$100.00	$200.00	P
RETIN-A 0.01% GEL	2	Generic	$15.00	$30.00	P
RETIN-A 0.025% GEL	2	Generic	$15.00	$30.00	P
RETIN-A MICRO 0.04% GEL	2	Generic	$15.00	$30.00	P
RETIN-A MICRO 0.1% GEL	2	Generic	$15.00	$30.00	P
RETIN-A MICRO PUMP 0.06% GEL	5	Specialty Tier	33%	33%	P
RETIN-A MICRO PUMP 0.08% GEL	4	Non-Preferred Brand	$100.00	$200.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RETROVIR 100mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
REVATIO 10 MG/ML ORAL SUSP	4	Non-Preferred Brand	$100.00	$200.00	P
REVATIO 20MG TABLET	5	Specialty Tier	33%	33%	P
REVLIMID 10 MG CAPSULE	5	Specialty Tier	33%	33%	None
REVLIMID 15MG CAPSULE 21 BOT	5	Specialty Tier	33%	33%	None
REVLIMID 2.5 MG CAPSULE	5	Specialty Tier	33%	33%	None
REVLIMID 20 MG CAPSULE	5	Specialty Tier	33%	33%	None
REVLIMID 25 MG CAPSULE	5	Specialty Tier	33%	33%	None
REVLIMID 5 MG CAPSULE	5	Specialty Tier	33%	33%	None
REXULTI 0.25 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
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 Brand	$100.00	$200.00	None
REXULTI 1 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REXULTI 2 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REXULTI 3 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REXULTI 4 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
REYATAZ 150MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
REYATAZ 200MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
REYATAZ 300MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
REYATAZ 50 MG POWDER PACKET	4	Non-Preferred Brand	$100.00	$200.00	None
RHOFADE 1% CREAM (g)	4	Non-Preferred Brand	$100.00	$200.00	None
RHOPRESSA 0.02% OPHTH SOLUTION Drops	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIBASPHERE 200 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIBASPHERE 600MG TABLET	2	Generic	$15.00	$30.00	None
RIBASPHERE RibaPak	2	Generic	$15.00	$30.00	None
RIBASPHERE RibaPak 600mg/1	2	Generic	$15.00	$30.00	None
RIBAVIRIN 200 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIBAVIRIN 200MG TABLET 168 BOT	2	Generic	$15.00	$30.00	None
RIDAURA 3 MG CAPSULE	3	Preferred Brand	$45.00	$90.00	None
RIFABUTIN 150 MG CAPSULE [Mycobutin]	2	Generic	$15.00	$30.00	None
RIFADIN 150MG CAPSULE	2	Generic	$15.00	$30.00	None
RIFAMATE 150/300 CAPSULE	2	Generic	$15.00	$30.00	None
RIFAMPIN 150 MG CAPSULE	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIFAMPIN 300 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIFAMPIN IV 600 MG VIAL	2	Generic	$15.00	$30.00	None
RIFATER 50/300/120 TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RILUTEK 50 MG TABLET	5	Specialty Tier	33%	33%	None
RILUZOLE 50 MG TABLET [Rilutek]	2	Generic	$15.00	$30.00	None
Rimantadine 100mg/1 100 TABLET BOTTLE	2	Generic	$15.00	$30.00	None
RIOMET 500MG/5ML SOLUTION ORAL	4	Non-Preferred Brand	$100.00	$200.00	None
RISEDRONATE SOD DR 35 MG TABLET DR [Atelvia]	2	Generic	$15.00	$30.00	None
RISEDRONATE SODIUM 150 MG TAB [Actonel]	2	Generic	$15.00	$30.00	None
RISEDRONATE SODIUM 30 MG TABLET [Actonel]	2	Generic	$15.00	$30.00	None
RISEDRONATE SODIUM 35 MG TAB [Actonel]	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISEDRONATE SODIUM 35 MG TABLET [Actonel]	2	Generic	$15.00	$30.00	None
RISEDRONATE SODIUM 35 MG TABLET [Actonel]	2	Generic	$15.00	$30.00	None
RISEDRONATE SODIUM 5 MG TABLET [Actonel]	2	Generic	$15.00	$30.00	None
RISPERDAL 0.25 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL 0.5 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL 1 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL 1MG/ML SOLUTION	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL 2 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL 3 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL 4 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RISPERDAL CONSTA 25MG SYR	3	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERDAL CONSTA 37.5MG SYR	3	Preferred Brand	$45.00	$90.00	None
RISPERDAL CONSTA 50MG SYR	3	Preferred Brand	$45.00	$90.00	None
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	3	Preferred Brand	$45.00	$90.00	None
RISPERIDONE 0.25 MG TABLET	2	Generic	$15.00	$30.00	None
RISPERIDONE 0.5 MG ODT	2	Generic	$15.00	$30.00	None
RISPERIDONE 0.5 MG TABLET	2	Generic	$15.00	$30.00	None
RISPERIDONE 1 MG ODT	2	Generic	$15.00	$30.00	None
RISPERIDONE 1 MG TABLET	2	Generic	$15.00	$30.00	None
RISPERIDONE 1 MG/ML SOLUTION	2	Generic	$15.00	$30.00	None
RISPERIDONE 2 MG ODT	2	Generic	$15.00	$30.00	None
RISPERIDONE 2 MG TABLET	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE 3 MG ODT	2	Generic	$15.00	$30.00	None
RISPERIDONE 3 MG TABLET	2	Generic	$15.00	$30.00	None
RISPERIDONE 4 MG ODT	2	Generic	$15.00	$30.00	None
RISPERIDONE 4 MG TABLET	2	Generic	$15.00	$30.00	None
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	2	Generic	$15.00	$30.00	None
RITALIN 10MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RITALIN 20MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RITALIN 5MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RITALIN LA 10MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
RITALIN LA 20MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
RITALIN LA 30MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RITALIN LA 40MG CAPSULE	4	Non-Preferred Brand	$100.00	$200.00	None
RITONAVIR 100 MG TABLET [Norvir]	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 1.5 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 13.3 MG/24HR PTCH	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 3 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 4.5 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 4.6 MG/24HR PATCH	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 6 MG CAPSULE	2	Generic	$15.00	$30.00	None
RIVASTIGMINE 9.5 MG/24HR PATCH	2	Generic	$15.00	$30.00	None
RIVELSA TABLET TBDSPK 3MO	2	Generic	$15.00	$30.00	None
RIZATRIPTAN 10 MG ODT [Maxalt-MLT]	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RIZATRIPTAN 10 MG TABLET [Maxalt]	2	Generic	$15.00	$30.00	None
RIZATRIPTAN 5 MG ODT [Maxalt-MLT]	2	Generic	$15.00	$30.00	None
RIZATRIPTAN 5 MG TABLET [Maxalt]	2	Generic	$15.00	$30.00	None
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	P
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	P
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	P
ROCKLATAN 0.02%-0.005% EYE DROPS	4	Non-Preferred Brand	$100.00	$200.00	None
ROPINIROLE HCL 0.25 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL 0.5 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL 1 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL 2 MG TABLET	2	Generic	$15.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROPINIROLE HCL 3 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL 4 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL 5 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL ER 12 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL ER 2 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL ER 4 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL ER 6 MG TABLET	2	Generic	$15.00	$30.00	None
ROPINIROLE HCL ER 8 MG TABLET	2	Generic	$15.00	$30.00	None
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor]	1	Preferred Generic	$8.00	$0.00	None
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor]	1	Preferred Generic	$8.00	$0.00	None
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor]	1	Preferred Generic	$8.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor]	1	Preferred Generic	$8.00	$0.00	None
ROTARIX VACCINE SUSPENSION	4	Non-Preferred Brand	$100.00	$200.00	None
ROTATEQ VACCINE Solution	6	Vaccines	$0.00	N/A	None
Rowasa Rectal 4 G 60 ml Kit 28X60	4	Non-Preferred Brand	$100.00	$200.00	None
Roweepra 1,000 mg tablet	2	Generic	$15.00	$30.00	None
ROWEEPRA 500 MG TABLET	2	Generic	$15.00	$30.00	None
Roweepra 750 mg tablet	2	Generic	$15.00	$30.00	None
ROWEEPRA XR 500 MG TABLET ER 24H	2	Generic	$15.00	$30.00	None
ROWEEPRA XR 750 MG TABLET ER 24H	2	Generic	$15.00	$30.00	None
ROXICODONE 15 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
ROXICODONE 30 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROXICODONE 5 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
ROZEREM 8 MG TABLET	4	Non-Preferred Brand	$100.00	$200.00	None
RUBRACA 200 MG TABLET	5	Specialty Tier	33%	33%	None
RUBRACA 250 MG TABLET	5	Specialty Tier	33%	33%	None
RUBRACA 300 MG TABLET	5	Specialty Tier	33%	33%	None
RUCONEST 2,100 UNIT VIAL	5	Specialty Tier	33%	33%	None
RYCLORA 2 MG/5 ML SOLUTION SYRUP	2	Generic	$15.00	$30.00	None
RYDAPT 25 MG CAPSULE	5	Specialty Tier	33%	33%	None
RYTARY ER 23.75 MG-95 MG CAP	4	Non-Preferred Brand	$100.00	$200.00	None
RYTARY ER 36.25 MG-145 MG CAP	4	Non-Preferred Brand	$100.00	$200.00	None
RYTARY ER 48.75 MG-195 MG CAP	4	Non-Preferred Brand	$100.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RYTARY ER 61.25 MG-245 MG CAP	4	Non-Preferred Brand	$100.00	$200.00	None
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$200.00	None
RYVENT 6 MG TABLET	2	Generic	$15.00	$30.00	None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Senior Advantage Medicare Medicaid Plan (HMO SNP) 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 $415 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" 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 2019 )

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.