2009 Medicare Part D Plan Formulary Information |
Blue MedicareRx Premier (S5596-007-0)
Sanctioned Plan
|
The Blue MedicareRx Premier (S5596-007-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 7 which includes: VA
|
Drugs Starting with Letter V
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
VAGIFEM 25MCG VAGINAL TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VALCYTE 450MG TABLET |
5 |
Tier 5. |
33% | N/A | None |
VALPROATE SOD 500MG/5ML VL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VALPROIC ACID 250MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:600 /30Days |
VALPROIC ACID SYRUP USP 250MG 16 FL OZ BOT |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VALTREX 1GM CAPLET (90 CT) |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:30 /1Days |
VALTREX 500MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:30 /1Days |
VANACET 5/500 TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:240 /30Days |
VANCOCIN HCL 125MG PULVULE |
5 |
Tier 5. |
33% | N/A | None |
VANCOCIN HCL 1G/200ML BAG |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANCOCIN HCL 250MG PULVULE |
5 |
Tier 5. |
33% | N/A | None |
VANCOCIN HCL 500MG/100ML |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VANCOMYCIN 500MG A/V VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VANCOMYCIN 5GM VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VANCOMYCIN HCL 10GM VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:140 /30Days |
VANOS 0.1% CREAM |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VANSPAR 7.5MG TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VANTIN 100MG TABLET (100 CT) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:42 /1Days |
VANTIN 200MG TABLET (20 CT) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:42 /1Days |
VAQTA 25 UNITS/0.5ML VIAL |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VAQTA HEPATITIS A VACCINE INACTIVATED ADULT 50UNITS/1MLVIAL BOX |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VARIVAX VACCINE W/DILUENT |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VECTIBIX SINGLE USE VIAL INJECTION 200MG/10ML |
5 |
Tier 5. |
33% | N/A | P |
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE |
5 |
Tier 5. |
33% | N/A | Q:800 /28Days |
VEETIDS 125MG/5ML ORAL SUSP |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VEETIDS 250MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VEETIDS 500MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VELCADE 3.5MG VIAL |
5 |
Tier 5. |
33% | N/A | None |
VELIVET TABLET TRIPHASIC 28 (7BEIGE+7ORANGE+7PINK) |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:28 /28Days |
VENLAFAXINE HCL 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:90 /30Days |
VENLAFAXINE HCL 25MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL 37.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:90 /30Days |
VENLAFAXINE HCL 50MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:90 /30Days |
VENLAFAXINE HCL 75MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:90 /30Days |
VENLAFAXINE HCL ER TAB |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:60 /30Days |
VENLAFAXINE HCL ER TAB 225 MG |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:30 /30Days |
VENLAFAXINE HCL ER TAB 37.5 MG |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:30 /30Days |
VENLAFAXINE HCL ER TAB 75 MG |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | Q:60 /30Days |
VENTAVIS INHALATION SOLUTION 10MCG AMPULE |
5 |
Tier 5. |
33% | N/A | None |
VENTOLIN HFA 90MCG INHALER |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:54 /30Days |
VERAMYST 27.5MCG SPRAY SUSPENSION |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:10 /30Days |
VERAPAMIL 120MG CAP PELLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 120MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL 180MG CAP PELLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL 2.5MG/ML AMPUL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VERAPAMIL 240MG CAP PELLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL 40MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL HCL 120MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL HCL 18OMG ER TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERAPAMIL HCL 240MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL HCL 80MG TABLET |
1 |
Tier 1 Preferred Generic |
$9.00 | $13.50 | None |
VERDESO 0.05% FOAM |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VERELAN 120MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VERELAN 180MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VERELAN 240MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VERELAN 360MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VERELAN PM 100MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VERELAN PM 200MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VERELAN PM 300MG CAP PELLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VESANOID 10MG CAPSULE |
5 |
Tier 5. |
33% | N/A | None |
VESICARE 10MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VESICARE 5MG TABLET (90 CT) |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VEXOL 1% EYE DROPS |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VFEND 200MG TABLET |
5 |
Tier 5. |
33% | N/A | P |
VFEND 40MG/ML SUSPENSION |
5 |
Tier 5. |
33% | N/A | None |
VFEND 50MG TABLET |
5 |
Tier 5. |
33% | N/A | P |
VFEND IV 200MG VIAL |
5 |
Tier 5. |
33% | N/A | None |
VIBRA-TAB S 100MG TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:60 /1Days |
VIBRAMYCIN 100MG CAPSULE |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:60 /1Days |
VIBRAMYCIN 25MG/5ML SUSP |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VIBRAMYCIN 50MG/5ML SYRUP |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VICODIN 5/500 TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VICODIN ES TABLET 7.5-750 |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:150 /30Days |
VICODIN HP TABLET 10-660 |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:180 /30Days |
VICOPROFEN 200/7.5 TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:480 /30Days |
VIDAZA 100MG VIAL |
5 |
Tier 5. |
33% | N/A | None |
VIDEX 2GM PEDIATRIC TUBEX |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIDEX 4GM PEDIATRIC TUBEX |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIDEX EC 125MG CAPSULE SA |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIDEX EC 200MG CAPSULE SA |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VIDEX EC 250MG CAPSULE SA |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VIDEX EC 400MG CAPSULE SA |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VIGAMOX 0.5% EYE DROPS |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VINBLASTINE 1MG/ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VINBLASTINE SULF 10MG VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VINCRISTINE 1MG/ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VINCRISTINE 1MG/ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
5 |
Tier 5. |
33% | N/A | None |
VINORELBINE 50MG/5ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VINORELBINE INJECTION 50MG/5ML |
4 |
Tier 4 Non-Specialty Injectable |
33% | 33% | None |
VIOKASE 16 TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIOKASE POWDER |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIOKASE TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIRACEPT 250MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIRACEPT 50MG/GM ORAL POWDER |
5 |
Tier 5. |
33% | N/A | None |
VIRACEPT 625MG TABLET |
5 |
Tier 5. |
33% | N/A | None |
VIRAMUNE 200MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIRAMUNE 50MG/5ML SUSP |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIRAZOLE 6GM VIAL |
5 |
Tier 5. |
33% | N/A | None |
VIREAD 300MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VIROPTIC 1% EYE DROPS |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:16 /30Days |
VISICOL 1.5GM TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VISTARIL 25MG CAPSULE |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VISTARIL 50MG CAPSULE |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VISTIDE 75MG/ML VIAL |
5 |
Tier 5. |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIVACTIL 10MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:180 /30Days |
VIVACTIL 5MG TABLET |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:120 /30Days |
VIVAGLOBIN SOL 160MG/ML 10ML VIAL |
5 |
Tier 5. |
33% | N/A | P |
VIVELLE-DOT 0.025MG PATCH |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:8 /28Days |
VIVELLE-DOT 0.0375MG PATCH 8 POUCH CRTN |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:8 /28Days |
VIVELLE-DOT 0.05MG PATCH 8 POUCH CRTN |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:8 /28Days |
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:8 /28Days |
VIVELLE-DOT 0.1MG PATCH 8 POUCH CRTN |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | Q:8 /28Days |
VIVOTIF BERNA 2B UNIT CAPSULE DELAYED RELEASE |
2 |
Tier 2 Preferred Brand |
$35.00 | $87.50 | None |
VOLTAREN 0.1% EYE DROPS |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VOLTAREN 75MG TABLET EC |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VOLTAREN-XR 100MG TABLET SR 24HR |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VOPAC 650MG-30MG TABLET |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | Q:180 /30Days |
VOSPIRE ER 4MG TABLET SR 12HR |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VOSPIRE ER 8MG TABLET SR 12HR |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | None |
VYTORIN 10/10MG TABLET (1000 CT) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | P Q:30 /30Days |
VYTORIN 10/20MG TABLET (1000 CT) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | P Q:30 /30Days |
VYTORIN 10/40MG TABLET (500 CT) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | P Q:30 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
3 |
Tier 3 Non-Preferred Brand or Generic |
$75.00 | $187.50 | P Q:30 /30Days |