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BlueMedicare Value Rx (PDP) (S5904-006-0)
Tier 1 (192)
Tier 2 (1095)
Tier 3 (642)
Tier 4 (546)
Tier 5 (706)
Tier 6 (168)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
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Cick on the first letter of your drug name to browse the formulary:

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2019 Medicare Part D Plan Formulary Information
BlueMedicare Value Rx (PDP) (S5904-006-0)
Benefit Details           
The BlueMedicare Value Rx (PDP) (S5904-006-0)
Formulary Drugs Starting with the Letter R

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $40.60 Deductible: $415 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 20%20%P
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex]   2 Generic $13.00$39.00Q:30
/30Days
RALOXIFENE HCL 60 MG TABLET [Evista]   2 Generic $13.00$39.00None
RAMIPRIL 1.25 MG CAPSULE   6* Select Care Drugs $0.00$0.00None
RAMIPRIL 10 MG CAPSULE   6* Select Care Drugs $0.00$0.00None
RAMIPRIL 2.5 MG CAPSULE   6* Select Care Drugs $0.00$0.00None
RAMIPRIL 5 MG CAPSULE   6* Select Care Drugs $0.00$0.00None
RANEXA ER 1,000 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
RANEXA ER 500 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
RANITIDINE 15 MG/ML SYRUP   2 Generic $13.00$39.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RANITIDINE 150 MG CAPSULE   2 Generic $13.00$39.00None
RANITIDINE 150 MG TABLET   1* Preferred Generic $0.00$0.00None
RANITIDINE 300 MG CAPSULE   2 Generic $13.00$39.00None
RANITIDINE 300 MG TABLET   1* Preferred Generic $0.00$0.00None
RANOLAZINE ER 1,000 MG TABLET ER 12H [Ranexa]   3 Preferred Brand 20%20%Q:60
/30Days
RANOLAZINE ER 500 MG TABLET ER 12H [Ranexa]   3 Preferred Brand 20%20%Q:60
/30Days
RAPAFLO 4 MG CAPSULE   3 Preferred Brand 20%20%Q:30
/30Days
RAPAFLO 8 MG CAPSULE   3 Preferred Brand 20%20%Q:30
/30Days
RAPAMUNE 1MG/ML ORAL TUBEX   5 Specialty Tier 25%N/AP
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REBETOL 40MG/ML SOLUTION   4 Non-Preferred Drug 50%50%None
RECLIPSEN 28 DAY TABLET [Solia]   2 Generic $13.00$39.00None
RECOMBIVAX HB 10 MCG/ML SYR   3 Preferred Brand 20%20%P
RECOMBIVAX HB 40MCG/ML VIAL   3 Preferred Brand 20%20%P
REGRANEX 0.01% GEL   5 Specialty Tier 25%N/AP Q:15
/30Days
RELENZA 5MG DISKHALER   4 Non-Preferred Drug 50%50%None
RELISTOR 12 MG/0.6 ML SYRINGE   5 Specialty Tier 25%N/AP
RELISTOR 12 MG/0.6 ML VIAL   5 Specialty Tier 25%N/AP
RELISTOR 150 MG TABLET   5 Specialty Tier 25%N/AP
RELISTOR 8 MG/0.4 ML SYRINGE   5 Specialty Tier 25%N/AP
REPAGLINIDE 0.5 MG TABLET [Prandin]   6* Select Care Drugs $0.00$0.00Q:960
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REPAGLINIDE 1 MG TABLET [Prandin]   6* Select Care Drugs $0.00$0.00Q:480
/30Days
REPAGLINIDE 2 MG TABLET [Prandin]   6* Select Care Drugs $0.00$0.00Q:240
/30Days
REPATHA 140 MG/ML SURECLICK   3 Preferred Brand 20%20%P Q:2
/28Days
REPATHA 140 MG/ML SYRINGE   3 Preferred Brand 20%20%P Q:2
/28Days
REPATHA 420 MG/3.5ML PUSHTRONX   3 Preferred Brand 20%20%P Q:4
/30Days
RESCRIPTOR 200 MG TABLET   4 Non-Preferred Drug 50%50%Q:180
/30Days
RESTASIS 0.05% EYE EMULSION   3 Preferred Brand 20%20%P Q:60
/30Days
RETACRIT 10,000 UNIT/ML VIAL   4 Non-Preferred Drug 50%50%P
RETACRIT 2,000 UNIT/ML VIAL   4 Non-Preferred Drug 50%50%P
RETACRIT 3,000 UNIT/ML VIAL   4 Non-Preferred Drug 50%50%P
RETACRIT 4,000 UNIT/ML VIAL   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RETACRIT 40,000 UNIT/ML VIAL   4 Non-Preferred Drug 50%50%P
REVLIMID 10 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
REVLIMID 15MG CAPSULE 21 BOT   5 Specialty Tier 25%N/AP Q:21
/28Days
REVLIMID 2.5 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
REVLIMID 20 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
REVLIMID 25 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
REVLIMID 5 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
REXULTI 0.25 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
REXULTI 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
REXULTI 1 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
REXULTI 2 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/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/AP Q:30
/30Days
REXULTI 4 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
REYATAZ 150MG CAPSULE   5 Specialty Tier 25%N/AQ:30
/30Days
REYATAZ 200MG CAPSULE   5 Specialty Tier 25%N/AQ:60
/30Days
REYATAZ 300MG CAPSULE   5 Specialty Tier 25%N/AQ:30
/30Days
REYATAZ 50 MG POWDER PACKET   5 Specialty Tier 25%N/AQ:240
/30Days
RIBASPHERE 200 MG CAPSULE   2 Generic $13.00$39.00None
RIBASPHERE 600MG TABLET   5 Specialty Tier 25%N/ANone
RIBASPHERE RibaPak 600mg/1   5 Specialty Tier 25%N/ANone
RIBAVIRIN 200 MG CAPSULE   2 Generic $13.00$39.00None
RIBAVIRIN 200MG TABLET 168 BOT   2 Generic $13.00$39.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RIDAURA 3 MG CAPSULE   5 Specialty Tier 25%N/ANone
RIFABUTIN 150 MG CAPSULE [Mycobutin]   5 Specialty Tier 25%N/ANone
RIFAMPIN 150 MG CAPSULE   2 Generic $13.00$39.00None
RIFAMPIN 300 MG CAPSULE   2 Generic $13.00$39.00None
RIFAMPIN IV 600 MG VIAL   5 Specialty Tier 25%N/ANone
RILUZOLE 50 MG TABLET [Rilutek]   3 Preferred Brand 20%20%None
RISEDRONATE SOD DR 35 MG TABLET DR [Atelvia]   2 Generic $13.00$39.00Q:4
/28Days
RISEDRONATE SODIUM 150 MG TAB [Actonel]   2 Generic $13.00$39.00Q:1
/28Days
RISEDRONATE SODIUM 30 MG TABLET [Actonel]   2 Generic $13.00$39.00Q:30
/30Days
RISEDRONATE SODIUM 35 MG TAB [Actonel]   2 Generic $13.00$39.00Q:4
/28Days
RISEDRONATE SODIUM 35 MG TABLET [Actonel]   2 Generic $13.00$39.00Q:4
/28Days
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 $13.00$39.00Q:4
/28Days
RISEDRONATE SODIUM 5 MG TABLET [Actonel]   2 Generic $13.00$39.00Q:30
/30Days
RISPERDAL CONSTA 25MG SYR   5 Specialty Tier 25%N/AP Q:2
/28Days
RISPERDAL CONSTA 37.5MG SYR   5 Specialty Tier 25%N/AP Q:2
/28Days
RISPERDAL CONSTA 50MG SYR   5 Specialty Tier 25%N/AP Q:2
/28Days
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL   4 Non-Preferred Drug 50%50%P Q:2
/28Days
RISPERIDONE 0.25 MG TABLET   1* Preferred Generic $0.00$0.00P Q:60
/30Days
RISPERIDONE 0.5 MG ODT   2 Generic $13.00$39.00P Q:60
/30Days
RISPERIDONE 0.5 MG TABLET   1* Preferred Generic $0.00$0.00P Q:60
/30Days
RISPERIDONE 1 MG ODT   2 Generic $13.00$39.00P Q:60
/30Days
RISPERIDONE 1 MG TABLET   1* Preferred Generic $0.00$0.00P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RISPERIDONE 1 MG/ML SOLUTION   2 Generic $13.00$39.00P Q:480
/30Days
RISPERIDONE 2 MG ODT   2 Generic $13.00$39.00P Q:60
/30Days
RISPERIDONE 2 MG TABLET   1* Preferred Generic $0.00$0.00P Q:60
/30Days
RISPERIDONE 3 MG ODT   3 Preferred Brand 20%20%P Q:60
/30Days
RISPERIDONE 3 MG TABLET   1* Preferred Generic $0.00$0.00P Q:60
/30Days
RISPERIDONE 4 MG ODT   3 Preferred Brand 20%20%P Q:120
/30Days
RISPERIDONE 4 MG TABLET   1* Preferred Generic $0.00$0.00P Q:120
/30Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK   2 Generic $13.00$39.00P Q:60
/30Days
RITONAVIR 100 MG TABLET [Norvir]   3 Preferred Brand 20%20%Q:360
/30Days
RIVASTIGMINE 1.5 MG CAPSULE   2 Generic $13.00$39.00None
RIVASTIGMINE 13.3 MG/24HR PTCH   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RIVASTIGMINE 3 MG CAPSULE   2 Generic $13.00$39.00None
RIVASTIGMINE 4.5 MG CAPSULE   2 Generic $13.00$39.00None
RIVASTIGMINE 4.6 MG/24HR PATCH   3 Preferred Brand 20%20%None
RIVASTIGMINE 6 MG CAPSULE   2 Generic $13.00$39.00None
RIVASTIGMINE 9.5 MG/24HR PATCH   3 Preferred Brand 20%20%None
RIZATRIPTAN 10 MG ODT [Maxalt-MLT]   2 Generic $13.00$39.00Q:18
/30Days
RIZATRIPTAN 10 MG TABLET [Maxalt]   2 Generic $13.00$39.00Q:18
/30Days
RIZATRIPTAN 5 MG ODT [Maxalt-MLT]   2 Generic $13.00$39.00Q:18
/30Days
RIZATRIPTAN 5 MG TABLET [Maxalt]   2 Generic $13.00$39.00Q:18
/30Days
ROPINIROLE HCL 0.25 MG TABLET   2 Generic $13.00$39.00None
ROPINIROLE HCL 0.5 MG TABLET   2 Generic $13.00$39.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ROPINIROLE HCL 1 MG TABLET   2 Generic $13.00$39.00None
ROPINIROLE HCL 2 MG TABLET   2 Generic $13.00$39.00None
ROPINIROLE HCL 3 MG TABLET   2 Generic $13.00$39.00None
ROPINIROLE HCL 4 MG TABLET   2 Generic $13.00$39.00None
ROPINIROLE HCL 5 MG TABLET   2 Generic $13.00$39.00None
ROSUVASTATIN CALCIUM 10 MG TAB [Crestor]   6* Select Care Drugs $0.00$0.00Q:45
/30Days
ROSUVASTATIN CALCIUM 20 MG TAB [Crestor]   6* Select Care Drugs $0.00$0.00Q:45
/30Days
Rosuvastatin Calcium 40 mg Film Coated Tablet [Crestor]   6* Select Care Drugs $0.00$0.00Q:30
/30Days
ROSUVASTATIN CALCIUM 5 MG TAB [Crestor]   6* Select Care Drugs $0.00$0.00Q:45
/30Days
ROTARIX VACCINE SUSPENSION   3 Preferred Brand 20%20%None
ROTATEQ VACCINE Solution   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Roweepra 1,000 mg tablet   2 Generic $13.00$39.00None
ROWEEPRA 500 MG TABLET   2 Generic $13.00$39.00None
Roweepra 750 mg tablet   2 Generic $13.00$39.00None
RUBRACA 200 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
RUBRACA 250 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
RUBRACA 300 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
RYDAPT 25 MG CAPSULE   5 Specialty Tier 25%N/AP Q:240
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D BlueMedicare Value Rx (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 $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.