2016 Rocky Mountain Plus Plan + Rx (Cost) Formulary



Below is the Formulary, or drug list, for Rocky Mountain Plus Plan + Rx (Cost) from Rocky Mountain Health Maintenance Organization This formulary is a list of prescription medications that are covered under Rocky Mountain Health Maintenance Organization's 2016 Medicare Advantage Plan. The Rocky Mountain Plus Plan + Rx (Cost) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $3310. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $3310 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2016 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Rocky Mountain Plus Plan + Rx (Cost) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.

See More on Rocky Mountain Plus Plan + Rx (Cost)





Plan Name:
Rocky Mountain Plus Plan + Rx (Cost)
Plan ID:
H0602-019
Provider: Rocky Mountain Health Maintenance Organization
Plan Year:2016
Premium:$109.50
Deductible:$0
Initial Coverage Limit:$3310
Coverage Area:Colorado




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: S

Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  T  U  V  W  X  Y  Z 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Sabril 500mg 100 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N
Sabril 50mg/mL 50 Packet In 1 Carton > 10 Ml In 1 Packet
5
N N 33%N33%N33%N
Saizen 1 Kit In 1 Carton * 3 Ml In 1 Vial, Glass * 3.5 Ml In 1 Vial, Glass
5
Y N 33%N33%N33%N
Saizen Clickeasy 1 Kit In 1 Carton * 1.51 Ml In 1 Vial, Glass * 1.51 Ml In 1 Cartridge
5
Y N 33%N33%N33%N
Sandostatin Lar Depot 1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Single-use
5
N N 33%N33%N33%N
Sandostatin Lar Depot 1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Single-use
5
N N 33%N33%N33%N
Sandostatin Lar Depot 1 Kit In 1 Kit * 2.5 Ml In 1 Syringe * .75 Ml In 1 Packet * 5 Ml In 1 Vial, Single-use
5
N N 33%N33%N33%N
Savella 1 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
60 30 N N $40N$40NNAN
Savella 100mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $40N$40NNAN
Savella 12.5mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $40N$40NNAN
Savella 25mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $40N$40NNAN
Savella 50mg 60 Tablet, Film Coated In 1 Bottle
3
60 30 N N $40N$40NNAN
Selegiline Hydrochloride 5mg 60 Capsule In 1 Bottle
2
N N $20N$20NNAN
Selegiline Hydrochloride 5mg 500 Tablet In 1 Bottle
2
N N $20N$20NNAN
Selenium Sulfide 2.5mg/100mL 118 Ml In 1 Bottle
2
N N $20N$20NNAN
Selzentry 150mg 60 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N
Selzentry 300mg 60 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N
Sensipar 30mg 30 Tablet, Coated In 1 Bottle, Plastic
3
N N $40N$40NNAN
Sensipar 60mg 30 Tablet, Coated In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Sensipar 90mg 30 Tablet, Coated In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Serevent 50ug 60 Powder, Metered In 1 Inhaler
3
60 30 N N $40N$40NNAN
Seroquel 50mg 100 Tablet, Extended Release In 1 Box, Unit-dose
4
60 30 N Y $60N$60NNAN
Seroquel 150mg 100 Tablet, Extended Release In 1 Dose Pack
4
60 30 N Y $60N$60NNAN
Seroquel 200mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
4
30 30 N Y $60N$60NNAN
Seroquel 300mg 60 Tablet, Extended Release In 1 Bottle
4
60 30 N Y $60N$60NNAN
Seroquel 400mg 10 Blister Pack In 1 Carton > 10 Tablet, Extended Release In 1 Blister Pack
4
60 30 N Y $60N$60NNAN
Serostim 1 Kit In 1 Carton * 1 Ml In 1 Vial * 3.5 Ml In 1 Vial, Glass
5
Y N 33%N33%N33%N
Serostim 1 Kit In 1 Carton * 1 Ml In 1 Vial * 1 Ml In 1 Vial
5
Y N 33%N33%N33%N
Serostim 1 Kit In 1 Carton * 1 Ml In 1 Vial * 1 Ml In 1 Vial
5
Y N 33%N33%N33%N
Sertraline Hydrochloride 20mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
2
N N $20N$20NNAN
Sertraline Hydrochloride 25mg 30 Tablet In 1 Bottle
1
N N $3N$3NNAN
Sertraline Hydrochloride 50mg 30 Tablet In 1 Bottle
1
N N $3N$3NNAN
Sertraline Hydrochloride 100mg 30 Tablet In 1 Bottle
1
N N $3N$3NNAN
Signifor .3mg/mL 60 Package In 1 Box
5
60 30 N N 33%N33%N33%N
Signifor .6mg/mL 60 Package In 1 Box
5
60 30 N N 33%N33%N33%N
Signifor .9mg/mL 60 Package In 1 Box
5
60 30 N N 33%N33%N33%N
Sildenafil 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
2
90 30 Y N $20N$20NNAN
Silenor 3mg 100 Tablet In 1 Bottle
3
30 30 N N $40N$40NNAN
Silenor 6mg 100 Tablet In 1 Bottle
3
30 30 N N $40N$40NNAN
Silver Sulfadiazene 10g/1000g 50 G In 1 Jar
2
N N $20N$20NNAN
Simbrinza 2; 10mg/mL; mg/mL 8 Ml In 1 Bottle, Dropper
3
N N $40N$40NNAN
Simponi 50mg/.5mL 1 Syringe, Glass In 1 Carton > .5 Ml In 1 Syringe, Glass
5
Y N 33%N33%N33%N
Simponi 100mg/mL 1 Syringe, Glass In 1 Carton > 1 Ml In 1 Syringe, Glass
5
Y N 33%N33%N33%N
Simponi Aria 50mg/4mL 1 Vial, Single-use In 1 Carton > 4 Ml In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Simvastatin 10mg 30 Tablet, Film Coated In 1 Bottle
1
30 30 N N $3N$3NNAN
Simvastatin 5mg 90 Tablet, Film Coated In 1 Bottle
1
30 30 N N $3N$3NNAN
Simvastatin 20mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N $3N$3NNAN
Simvastatin 40mg 500 Tablet, Film Coated In 1 Bottle
1
30 30 N N $3N$3NNAN
Simvastatin 80mg 1000 Tablet, Film Coated In 1 Bottle
1
30 30 N N $3N$3NNAN
Sirolimus .5mg 100 Tablet, Film Coated In 1 Bottle
2
Y N $20N$20NNAN
Sirturo 100mg 188 Tablet In 1 Bottle
5
188 168 Y N 33%N33%N33%N
Sodium Chloride 4.5g/1000mL 1000 Ml In 1 Bag
2
N N $20N$20NNAN
Sodium Chloride 9g/1000mL 4 Bag In 1 Package > 100 Ml In 1 Bag
2
N N $20N$20NNAN
Sodium Chloride 3g/100mL 500 Ml In 1 Bag
2
N N $20N$20NNAN
Sodium Chloride 5g/100mL 500 Ml In 1 Bag
2
N N $20N$20NNAN
Sodium Chloride 2.92g/20mL 25 Vial In 1 Tray > 20 Ml In 1 Vial
2
N N $20N$20NNAN
Sodium Chloride 900mg/100mL 9 Bottle, Plastic In 1 Case > 1500 Ml In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sodium Lactate 5.6g/10mL 25 Vial, Single-dose In 1 Tray > 10 Ml In 1 Vial, Single-dose
2
N N $20N$20NNAN
Sodium Polystyrene Sulfonate 15g/60mL 473 Ml In 1 Bottle
2
N N $20N$20NNAN
Soltamox 10mg/5mL 1 Bottle In 1 Carton > 150 Ml In 1 Bottle
4
N N $60N$60NNAN
Solu-cortef 250mg/2mL 1 Vial, Single-dose In 1 Carton > 2 Ml In 1 Vial, Single-dose
4
Y N $60N$60NNAN
Somatuline Depot 60mg/.2mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .2 Ml In 1 Syringe
5
1 28 N N 33%N33%N33%N
Somatuline Depot 90mg/.3mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .3 Ml In 1 Syringe
5
1 28 N N 33%N33%N33%N
Somatuline Depot 120mg/.5mL 1 Pouch In 1 Carton > 1 Syringe In 1 Pouch > .5 Ml In 1 Syringe
5
1 28 N N 33%N33%N33%N
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N 33%N33%N33%N
Somavert 1 Kit In 1 Package
5
N N 33%N33%N33%N
Somavert 1 Kit In 1 Package * 1 Ml In 1 Vial, Single-dose
5
N N 33%N33%N33%N
Sorine 80mg 100 Blister Pack In 1 Carton
2
N N $20N$20NNAN
Sorine 120mg 100 Blister Pack In 1 Carton
2
N N $20N$20NNAN
Sorine 160mg 100 Blister Pack In 1 Carton
2
N N $20N$20NNAN
Sorine 240mg 100 Blister Pack In 1 Carton
2
N N $20N$20NNAN
Sotalol Hydrochloride 240mg 100 Tablet In 1 Bottle
2
N N $20N$20NNAN
Sotalol Hydrochloride 160mg 100 Tablet In 1 Bottle
2
N N $20N$20NNAN
Sotalol Hydrochloride 120mg 100 Tablet In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sotalol Hydrochloride 80mg 100 Tablet In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sovaldi 400mg 28 Tablet, Film Coated In 1 Bottle
5
28 28 Y N 33%N33%N33%N
Spiriva 18ug 9 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
30 30 N N $40N$40NNAN
Spironolactone 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $20N$20NNAN
Spironolactone 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $20N$20NNAN
Spironolactone 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $20N$20NNAN
Spironolactone And Hydrochlorothiazide 25; 25mg/1; mg 500 Tablet In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sporanox 10mg/mL 150 Ml In 1 Bottle
4
N N $60N$60NNAN
Sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N $20N$20NNAN
Sprycel 70mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sprycel 20mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60 30 Y N 33%N33%N33%N
Sprycel 50mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sprycel 100mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sprycel 80mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sprycel 140mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sronyx 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N $20N$20NNAN
Ssd Cream 10g/1000g 85 G In 1 Tube
2
N N $20N$20NNAN
Stavudine 15mg 60 Capsule In 1 Bottle, Plastic
2
N N $20N$20NNAN
Stavudine 20mg 60 Capsule In 1 Bottle, Plastic
2
N N $20N$20NNAN
Stavudine 30mg 60 Capsule In 1 Bottle
2
N N $20N$20NNAN
Stavudine 40mg 60 Capsule In 1 Bottle
2
N N $20N$20NNAN
Stelara 45mg/.5mL 1 Syringe In 1 Carton > .5 Ml In 1 Syringe
5
Y N 33%N33%N33%N
Stelara 90mg/mL 1 Syringe In 1 Carton > 1 Ml In 1 Syringe
5
Y N 33%N33%N33%N
Sterile Water 1mL/mL 16 Container In 1 Case > 1000 Ml In 1 Container
2
N N $20N$20NNAN
Stimate 1.5mg/mL 1 Bottle, Spray In 1 Carton > 2.5 Ml In 1 Bottle, Spray
4
N N $60N$60NNAN
Stivarga 40mg 3 Bottle, Plastic In 1 Box
5
84 28 Y N 33%N33%N33%N
Strattera 10mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Strattera 25mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Strattera 40mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Strattera 18mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Strattera 60mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Strattera 80mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Strattera 100mg 30 Capsule In 1 Bottle
3
N N $40N$40NNAN
Streptomycin 1g 10 Vial In 1 Box
2
N N $20N$20NNAN
Stribild 150; 150; 200; 300mg/1; mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Sucralfate 1g 500 Tablet In 1 Bottle
2
N N $20N$20NNAN
Sulfacetamide Sodium 100mg/mL 118 Ml In 1 Bottle
2
N N $20N$20NNAN
Sulfacetamide Sodium 100mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
2
N N $20N$20NNAN
Sulfacetamide Sodium And Prednisolone Sodium Phosp 2.5; 100mg/mL; mg/mL 10 Ml In 1 Bottle
2
N N $20N$20NNAN
Sulfamethoxazole And Trimethoprim 400; 80mg/1; mg 500 Tablet In 1 Bottle, Plastic
1
N N $3N$3NNAN
Sulfamethoxazole And Trimethoprim 80; 16mg/mL; mg/mL 10 Vial, Multi-dose In 1 Carton
2
N N $20N$20NNAN
Sulfamethoxazole And Trimethoprim 800; 160mg/1; mg 100 Tablet In 1 Bottle
1
N N $3N$3NNAN
Sulfasalazine 500mg 500 Tablet In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sulfasalazine 500mg 300 Tablet, Delayed Release In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sulindac 150mg 100 Tablet In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sulindac 200mg 500 Tablet In 1 Bottle, Plastic
2
N N $20N$20NNAN
Sumatriptan 20mg/100uL 6 Container In 1 Box
2
12 28 N N $20N$20NNAN
Sumatriptan 5mg/100uL 6 Container In 1 Box
2
12 28 N N $20N$20NNAN
Sumatriptan 100mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 28 N N $20N$20NNAN
Sumatriptan 50mg 1 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 28 N N $20N$20NNAN
Sumatriptan Succinate 6mg/.5mL 2 Syringe In 1 Package > .5 Ml In 1 Syringe
2
4 28 N N $20N$20NNAN
Sumatriptan Succinate 25mg 9 Blister Pack In 1 Carton > 9 Tablet In 1 Blister Pack
2
18 28 N N $20N$20NNAN
Sumatriptan Succinate 6mg/.5mL 1 Vial, Single-dose In 1 Carton > .5 Ml In 1 Vial, Single-dose
2
4 28 N N $20N$20NNAN
Suprax 100mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N $60N$60NNAN
Suprax 200mg 1 Blister Pack In 1 Carton > 10 Tablet, Chewable In 1 Blister Pack
4
N N $60N$60NNAN
Suprax 500mg/5mL 20 Ml In 1 Bottle
4
N N $60N$60NNAN
Surmontil 25mg 100 Capsule In 1 Bottle
4
Y N $60N$60NNAN
Surmontil 50mg 100 Capsule In 1 Bottle
4
Y N $60N$60NNAN
Surmontil 100mg 100 Capsule In 1 Bottle
4
Y N $60N$60NNAN
Sustiva 50mg 30 Capsule, Gelatin Coated In 1 Bottle
4
N N $60N$60NNAN
Sustiva 200mg 90 Capsule, Gelatin Coated In 1 Bottle
4
N N $60N$60NNAN
Sustiva 600mg 30 Tablet, Film Coated In 1 Bottle
4
N N $60N$60NNAN
Sutent 12.5mg 28 Capsule In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sutent 25mg 28 Capsule In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sutent 50mg 28 Capsule In 1 Bottle
5
30 30 Y N 33%N33%N33%N
Sylatron 1 Kit In 1 Carton
5
4 28 Y N 33%N33%N33%N
Sylatron 1 Kit In 1 Carton
5
4 28 Y N 33%N33%N33%N
Sylatron 1 Kit In 1 Carton
5
4 28 Y N 33%N33%N33%N
Sylvant 100mg 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Synagis 50mg/.5mL .5 Ml In 1 Vial, Single-dose
5
N N 33%N33%N33%N
Synarel 2mg/mL 1 Bottle, Spray In 1 Carton > 8 Ml In 1 Bottle, Spray
5
N N 33%N33%N33%N
Synercid 350; 150mg/5mL; mg/5mL 10 Vial, Glass In 1 Carton
5
N N 33%N33%N33%N
Synribo 3.5mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
28 28 Y N 33%N33%N33%N



Medicare Help's Additional Notes:

Coverage Levels for H0602-019

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $3310
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4850 in 2016.
4.Catastrophic: Anything over $4850 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2016 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2015
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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