2023 Medicare Part D Plan Formulary Information |
Geisinger Gold Classic 360 Rx (HMO) (H3954-160-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Geisinger Gold Classic 360 Rx (HMO) (H3954-160-0) Formulary Drugs Starting with the Letter R in Huntingdon County, PA: CMS MA Region 6 which includes: PA
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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 |
6 |
Vaccines |
$0.00 | N/A | P |
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex] |
2 |
Generic |
$20.00 | $0.00 | None |
RADICAVA ORS STARTER KIT ORAL SUSPENSION |
5 |
Specialty Tier |
33% | N/A | P Q:70 /28Days |
RALOXIFENE HCL 60 MG TABLET [Evista] |
2 |
Generic |
$20.00 | $0.00 | None |
RAMELTEON 8 MG TABLET [Rozerem] |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days |
RAMIPRIL 1.25 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days |
RAMIPRIL 10 MG CAPSULE [Altace] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days |
RAMIPRIL 2.5 MG CAPSULE [Altace] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days |
RAMIPRIL 5 MG CAPSULE [Altace] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days |
RANOLAZINE ER 1,000 MG TABLET 12H [Ranexa] |
2 |
Generic |
$20.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RANOLAZINE ER 500 MG TABLET 12H [Ranexa] |
2 |
Generic |
$20.00 | $0.00 | None |
RASAGILINE MESYLATE 0.5 MG TABLET [Azilect] |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days |
RASAGILINE MESYLATE 1 MG TABLET [Azilect] |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days |
RAVICTI 1.1 GRAM/ML LIQUID |
5 |
Specialty Tier |
33% | N/A | P Q:525 /30Days |
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF REBIDOSE 22 MCG/0.5 ML |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF REBIDOSE 44 MCG/0.5 ML |
5 |
Specialty Tier |
33% | N/A | Q:6 /28Days |
REBIF REBIDOSE TITRATION PACK |
5 |
Specialty Tier |
33% | N/A | Q:4 /28Days |
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL |
5 |
Specialty Tier |
33% | N/A | Q:4 /28Days |
RECLIPSEN 28 DAY TABLET [Solia] |
2 |
Generic |
$20.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RECOMBIVAX HB 10 MCG/ML SYR |
6 |
Vaccines |
$0.00 | N/A | P |
RECOMBIVAX HB 10 MCG/ML VIAL |
6 |
Vaccines |
$0.00 | N/A | P |
RECOMBIVAX HB 40MCG/ML VIAL |
6 |
Vaccines |
$0.00 | N/A | P |
RECOMBIVAX HB 5 MCG/0.5 ML VL VIAL |
6 |
Vaccines |
$0.00 | N/A | P |
RECTIV 0.4% OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | None |
REGRANEX 0.01% GEL |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
RELENZA 5MG DISKHALER |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:60 /180Days |
RELEUKO 300 MCG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
RELEUKO 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
RELISTOR 12 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:18 /30Days |
RELISTOR 12 MG/0.6 ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RELISTOR 8 MG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:12 /30Days |
RELYVRIO 3 GM-1 GM POWDER PACKET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
REPAGLINIDE 0.5 MG TABLET [Prandin] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:120 /30Days |
REPAGLINIDE 1 MG TABLET [Prandin] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:120 /30Days |
REPAGLINIDE 2 MG TABLET [Prandin] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:240 /30Days |
REPATHA 140 MG/ML SURECLICK PEN INJCTR |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /28Days |
REPATHA 140 MG/ML SYRINGE |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /28Days |
REPATHA 420 MG/3.5ML PUSHTRONX WEAR INJCT |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:4 /28Days |
RESTASIS MULTIDOSE 0.05% EYE DROPS |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | None |
RETACRIT 10,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:12 /28Days |
RETACRIT 2,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RETACRIT 20,000 UNIT/2 ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:12 /28Days |
RETACRIT 20,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:12 /28Days |
RETACRIT 3,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:12 /28Days |
RETACRIT 4,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:12 /28Days |
RETACRIT 40,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:6 /28Days |
RETEVMO 40 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
RETEVMO 80 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
REVCOVI 2.4 MG/1.5 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
REVLIMID 2.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REVLIMID 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 0.25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
REXULTI 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REXULTI 4 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
REYATAZ 50 MG POWDER PACKET |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:180 /30Days |
REZLIDHIA 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
REZUROCK 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
RHOPRESSA 0.02% OPHTH SOLUTION Drops |
3 |
Preferred Brand |
$47.00 | $70.50 | S Q:5 /30Days |
RIBAVIRIN 200 MG CAPSULE [Ribasphere] |
2 |
Generic |
$20.00 | $0.00 | None |
RIBAVIRIN 200 MG TABLET [Ribasphere] |
2 |
Generic |
$20.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIDAURA 3 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $70.50 | None |
RIFABUTIN 150 MG CAPSULE [Mycobutin] |
2 |
Generic |
$20.00 | $0.00 | None |
RIFAMPIN 150 MG CAPSULE |
2 |
Generic |
$20.00 | $0.00 | None |
RIFAMPIN 300 MG CAPSULE [Rimactane] |
2 |
Generic |
$20.00 | $0.00 | None |
RIFAMPIN IV 600 MG VIAL [Rifadin IV] |
2 |
Generic |
$20.00 | $0.00 | None |
RILUZOLE 50 MG TABLET [Rilutek] |
2 |
Generic |
$20.00 | $0.00 | None |
Rimantadine 100mg/1 100 TABLET BOTTLE |
2 |
Generic |
$20.00 | $0.00 | None |
RINVOQ ER 15 MG TABLET ER 24H |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
RINVOQ ER 30 MG TABLET 24H |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
RINVOQ ER 45 MG TABLET ER 24H |
5 |
Specialty Tier |
33% | N/A | P Q:56 /180Days |
RISEDRONATE SODIUM 150 MG TABLET [Actonel] |
2 |
Generic |
$20.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISEDRONATE SODIUM 30 MG TABLET [Actonel] |
2 |
Generic |
$20.00 | $0.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$20.00 | $0.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$20.00 | $0.00 | None |
RISEDRONATE SODIUM 35 MG TABLET [Actonel] |
2 |
Generic |
$20.00 | $0.00 | None |
RISEDRONATE SODIUM 5 MG TABLET [Actonel] |
2 |
Generic |
$20.00 | $0.00 | None |
RISEDRONATE SODIUM DR 35 MG TABLET DR [Atelvia] |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days |
RISPERDAL CONSTA 25MG SYR |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:2 /28Days |
RISPERDAL CONSTA 37.5MG SYR |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
RISPERDAL CONSTA 50MG SYR |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:2 /28Days |
RISPERIDONE 0.25 MG TABLET [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RISPERIDONE 0.5 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 0.5 MG TABLET [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 1 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 1 MG TABLET [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 1 MG/ML SOLUTION [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | Q:480 /30Days |
RISPERIDONE 2 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 2 MG TABLET [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 3 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 3 MG TABLET [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RISPERIDONE 4 MG ODT TABLET RAPDIS [Risperdal M-Tab] |
2 |
Generic |
$20.00 | $0.00 | Q:120 /30Days |
RISPERIDONE 4 MG TABLET [Risperdal] |
2 |
Generic |
$20.00 | $0.00 | 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 |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days |
RITONAVIR 100 MG TABLET [Norvir] |
2 |
Generic |
$20.00 | $0.00 | Q:360 /30Days |
RIVASTIGMINE 1.5 MG CAPSULE [Exelon] |
2 |
Generic |
$20.00 | $0.00 | None |
RIVASTIGMINE 13.3 MG/24HR PATCH [Exelon Patch] |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days |
RIVASTIGMINE 3 MG CAPSULE [Exelon] |
2 |
Generic |
$20.00 | $0.00 | None |
RIVASTIGMINE 4.5 MG CAPSULE [Exelon] |
2 |
Generic |
$20.00 | $0.00 | None |
RIVASTIGMINE 4.6 MG/24HR PATCH [Exelon Patch] |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days |
RIVASTIGMINE 6 MG CAPSULE [Exelon] |
2 |
Generic |
$20.00 | $0.00 | None |
RIVASTIGMINE 9.5 MG/24HR PATCH [Exelon Patch] |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days |
RIVELSA TABLET TBDSPK 3MO |
2 |
Generic |
$20.00 | $0.00 | None |
RIZATRIPTAN 10 MG ODT TABLET RAPDIS [Maxalt-MLT] |
2 |
Generic |
$20.00 | $0.00 | Q:16 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RIZATRIPTAN 10 MG TABLET [Maxalt] |
2 |
Generic |
$20.00 | $0.00 | Q:16 /28Days |
RIZATRIPTAN 5 MG ODT TABLET RAPDIS [Maxalt-MLT] |
2 |
Generic |
$20.00 | $0.00 | Q:16 /28Days |
RIZATRIPTAN 5 MG TABLET [Maxalt] |
2 |
Generic |
$20.00 | $0.00 | Q:16 /28Days |
ROCKLATAN 0.02%-0.005% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $70.50 | S Q:5 /30Days |
ROFLUMILAST 250 MCG TABLET [Daliresp] |
2 |
Generic |
$20.00 | $0.00 | P Q:30 /30Days |
ROFLUMILAST 500 MCG TABLET [Daliresp] |
2 |
Generic |
$20.00 | $0.00 | P Q:30 /30Days |
ROPINIROLE HCL 0.25 MG TABLET |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL 0.5 MG TABLET |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL 1 MG TABLET [Requip] |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL 2 MG TABLET [Requip] |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL 3 MG TABLET |
2 |
Generic |
$20.00 | $0.00 | 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 |
$20.00 | $0.00 | None |
ROPINIROLE HCL 5 MG TABLET |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL ER 12 MG TABLET 24H [Requip XL] |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL ER 2 MG TABLET 24H [Requip XL] |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL ER 4 MG TABLET 24H [Requip XL] |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL ER 6 MG TABLET 24H [Requip XL] |
2 |
Generic |
$20.00 | $0.00 | None |
ROPINIROLE HCL ER 8 MG TABLET 24H [Requip XL] |
2 |
Generic |
$20.00 | $0.00 | None |
ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:45 /30Days |
ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:45 /30Days |
ROSUVASTATIN CALCIUM 40 MG TABLET [Crestor] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:30 /30Days |
ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ROTARIX VACCINE SUSPENSION |
6 |
Vaccines |
$0.00 | N/A | None |
ROTATEQ VACCINE SOLUTION |
6 |
Vaccines |
$0.00 | N/A | None |
Rotavirus Vaccine, Live, Oral |
6 |
Vaccines |
$0.00 | N/A | None |
ROZLYTREK 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ROZLYTREK 200 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
RUBRACA 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
RUBRACA 250 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
RUBRACA 300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
RUFINAMIDE 200 MG TABLET [Banzel] |
2 |
Generic |
$20.00 | $0.00 | P |
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [Banzel] |
2 |
Generic |
$20.00 | $0.00 | P |
RUFINAMIDE 400 MG TABLET [Banzel] |
2 |
Generic |
$20.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
RUKOBIA ER 600 MG TABLETLET 12H |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
RYBELSUS 14 MG TABLET |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:30 /30Days |
RYBELSUS 3 MG TABLET |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:30 /180Days |
RYBELSUS 7 MG TABLET |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:30 /30Days |
RYDAPT 25 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:224 /28Days |