Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (S5678-056-0) Benefit Details
The Health Net Orange Option 1 (S5678-056-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter V Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter V Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VAGIFEM 25MCG VAGINAL TABLET	3	Non-Preferred Brand	$90.00	$225.00	None
VALCYTE 450MG TABLET	5	Specialty	25%	N/A	P
VALPROATE SOD 500MG/5ML VL	4	Injectable	25%	N/A	None
VALPROIC ACID 250MG CAPSULE	3	Non-Preferred Brand	$90.00	$225.00	None
VALPROIC ACID SYRUP USP 250MG 16 FL OZ BOT	3	Non-Preferred Brand	$90.00	$225.00	None
VALTREX 1GM CAPLET (90 CT)	2	Preferred Brand	$44.00	$88.00	None
VALTREX 500MG TABLET	2	Preferred Brand	$44.00	$88.00	None
VANACET 5/500 TABLET	1	Preferred Generic	$2.00	$4.00	None
VANCOCIN HCL 1G/200ML BAG	4	Injectable	25%	N/A	None
VANCOCIN HCL 500MG/100ML	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VANCOMYCIN 500MG A/V VIAL	4	Injectable	25%	N/A	None
VANCOMYCIN 5GM VIAL	4	Injectable	25%	N/A	None
VANCOMYCIN HCL 10GM VIAL	4	Injectable	25%	N/A	None
VANDAZOLE 0.75% GEL WITH APPLICATOR	3	Non-Preferred Brand	$90.00	$225.00	None
VANSPAR 7.5MG TABLET	2	Preferred Brand	$44.00	$88.00	None
VANTAS IMPLANT 50MG 1 IMPLANT VIAL	4	Injectable	25%	N/A	None
VAQTA 25 UNITS/0.5ML VIAL	4	Injectable	25%	N/A	None
VAQTA HEPATITIS A VACCINE INACTIVATED ADULT 50UNITS/1MLVIAL BOX	4	Injectable	25%	N/A	None
VARIVAX VACCINE W/DILUENT	4	Injectable	25%	N/A	None
VASERETIC 10MG-25MG TABLET	2	Preferred Brand	$44.00	$88.00	Q:2 /1Days
VASOTEC 10MG TABLET	2	Preferred Brand	$44.00	$88.00	Q:2 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VASOTEC 2.5MG TABLET	2	Preferred Brand	$44.00	$88.00	Q:2 /1Days
VASOTEC 20MG TABLET	2	Preferred Brand	$44.00	$88.00	Q:2 /1Days
VASOTEC 5MG TABLET	2	Preferred Brand	$44.00	$88.00	Q:2 /1Days
VECTIBIX SINGLE USE VIAL INJECTION 200MG/10ML	5	Specialty	25%	N/A	P
VEETIDS 125MG/5ML ORAL SUSP	1	Preferred Generic	$2.00	$4.00	None
VEETIDS 250MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VEETIDS 500MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VELCADE 3.5MG VIAL	4	Injectable	25%	N/A	None
VELIVET TABLET TRIPHASIC 28 (7BEIGE+7ORANGE+7PINK)	1	Preferred Generic	$2.00	$4.00	Q:1 /1Days
VENLAFAXINE HCL 100MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VENLAFAXINE HCL 25MG TABLET	1	Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VENLAFAXINE HCL 37.5MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VENLAFAXINE HCL 50MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VENLAFAXINE HCL 75MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VENLAFAXINE HCL ER TAB	3	Non-Preferred Brand	$90.00	$225.00	Q:2 /1Days
VENLAFAXINE HCL ER TAB 225 MG	3	Non-Preferred Brand	$90.00	$225.00	Q:1 /1Days
VENLAFAXINE HCL ER TAB 37.5 MG	3	Non-Preferred Brand	$90.00	$225.00	Q:1 /1Days
VENLAFAXINE HCL ER TAB 75 MG	3	Non-Preferred Brand	$90.00	$225.00	Q:3 /1Days
VENTAVIS INHALATION SOLUTION 10MCG AMPULE	2	Preferred Brand	$44.00	$88.00	P
VENTOLIN HFA 90MCG INHALER	3	Non-Preferred Brand	$90.00	$225.00	Q:36 /30Days
VERAMYST 27.5MCG SPRAY SUSPENSION	2	Preferred Brand	$44.00	$88.00	Q:10 /30Days
VERAPAMIL 120MG CAP PELLET	1	Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERAPAMIL 120MG TABLET SA	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL 180MG CAP PELLET	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL 2.5MG/ML AMPUL	4	Injectable	25%	N/A	None
VERAPAMIL 240MG CAP PELLET	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL 40MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL HCL 120MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL HCL 18OMG ER TABLET	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL HCL 240MG TABLET SA	1	Preferred Generic	$2.00	$4.00	None
VERAPAMIL HCL 80MG TABLET	1	Preferred Generic	$2.00	$4.00	None
VERELAN 120MG CAP PELLET	2	Preferred Brand	$44.00	$88.00	None
VERELAN 180MG CAP PELLET	2	Preferred Brand	$44.00	$88.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERELAN 240MG CAP PELLET	2	Preferred Brand	$44.00	$88.00	None
VERELAN 360MG CAP PELLET	2	Preferred Brand	$44.00	$88.00	None
VESANOID 10MG CAPSULE	5	Specialty	25%	N/A	None
VESICARE 10MG TABLET	2	Preferred Brand	$44.00	$88.00	Q:1 /1Days
VESICARE 5MG TABLET (90 CT)	2	Preferred Brand	$44.00	$88.00	Q:1 /1Days
VEXOL 1% EYE DROPS	3	Non-Preferred Brand	$90.00	$225.00	Q:20 /30Days
VFEND 200MG TABLET	5	Specialty	25%	N/A	P
VFEND 40MG/ML SUSPENSION	5	Specialty	25%	N/A	P
VFEND 50MG TABLET	5	Specialty	25%	N/A	P
VFEND IV 200MG VIAL	5	Specialty	25%	N/A	None
VIBRA-TAB S 100MG TABLET	3	Non-Preferred Brand	$90.00	$225.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIBRAMYCIN 100MG CAPSULE	2	Preferred Brand	$44.00	$88.00	None
VIBRAMYCIN 25MG/5ML SUSP	2	Preferred Brand	$44.00	$88.00	None
VIBRAMYCIN 50MG/5ML SYRUP	2	Preferred Brand	$44.00	$88.00	None
VICODIN 5/500 TABLET	2	Preferred Brand	$44.00	$88.00	None
VICODIN ES TABLET 7.5-750	2	Preferred Brand	$44.00	$88.00	None
VICODIN HP TABLET 10-660	1	Preferred Generic	$2.00	$4.00	None
VIDAZA 100MG VIAL	5	Specialty	25%	N/A	P
VIDEX 2GM PEDIATRIC TUBEX	2	Preferred Brand	$44.00	$88.00	None
VIDEX 4GM PEDIATRIC TUBEX	2	Preferred Brand	$44.00	$88.00	None
VIDEX EC 125MG CAPSULE SA	2	Preferred Brand	$44.00	$88.00	None
VIDEX EC 200MG CAPSULE SA	2	Preferred Brand	$44.00	$88.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIDEX EC 250MG CAPSULE SA	2	Preferred Brand	$44.00	$88.00	None
VIDEX EC 400MG CAPSULE SA	2	Preferred Brand	$44.00	$88.00	None
VIGAMOX 0.5% EYE DROPS	2	Preferred Brand	$44.00	$88.00	Q:3 /30Days
VIMPAT TAB	3	Non-Preferred Brand	$90.00	$225.00	P
VIMPAT TAB	3	Non-Preferred Brand	$90.00	$225.00	P
VIMPAT TABS	3	Non-Preferred Brand	$90.00	$225.00	P
VIMPAT TABS	3	Non-Preferred Brand	$90.00	$225.00	P
VINBLASTINE 1MG/ML VIAL	4	Injectable	25%	N/A	None
VINBLASTINE SULF 10MG VIAL	4	Injectable	25%	N/A	None
VINCRISTINE 1MG/ML VIAL	4	Injectable	25%	N/A	None
VINCRISTINE 1MG/ML VIAL	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VINORELBINE 10MG/ML VIAL 5ML VIAL	4	Injectable	25%	N/A	None
VINORELBINE 50MG/5ML VIAL	4	Injectable	25%	N/A	None
VINORELBINE INJECTION 50MG/5ML	4	Injectable	25%	N/A	None
VIOKASE 16 TABLET	3	Non-Preferred Brand	$90.00	$225.00	None
VIOKASE POWDER	3	Non-Preferred Brand	$90.00	$225.00	None
VIOKASE TABLET	3	Non-Preferred Brand	$90.00	$225.00	None
VIRACEPT 250MG TABLET	3	Non-Preferred Brand	$90.00	$225.00	None
VIRACEPT 50MG/GM ORAL POWDER	2	Preferred Brand	$44.00	$88.00	None
VIRACEPT 625MG TABLET	3	Non-Preferred Brand	$90.00	$225.00	None
VIRAMUNE 200MG TABLET	2	Preferred Brand	$44.00	$88.00	None
VIRAMUNE 50MG/5ML SUSP	2	Preferred Brand	$44.00	$88.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIREAD 300MG TABLET	2	Preferred Brand	$44.00	$88.00	None
VIROPTIC 1% EYE DROPS	2	Preferred Brand	$44.00	$88.00	None
VISTARIL 25MG CAPSULE	2	Preferred Brand	$44.00	$88.00	None
VISTARIL 50MG CAPSULE	2	Preferred Brand	$44.00	$88.00	None
VISTIDE 75MG/ML VIAL	5	Specialty	25%	N/A	None
VIVACTIL 10MG TABLET	2	Preferred Brand	$44.00	$88.00	None
VIVACTIL 5MG TABLET	2	Preferred Brand	$44.00	$88.00	None
VIVAGLOBIN SOL 160MG/ML 10ML VIAL	5	Specialty	25%	N/A	P
VIVELLE-DOT 0.025MG PATCH	3	Non-Preferred Brand	$90.00	$225.00	Q:8 /28Days
VIVELLE-DOT 0.0375MG PATCH 8 POUCH CRTN	3	Non-Preferred Brand	$90.00	$225.00	Q:8 /28Days
VIVELLE-DOT 0.05MG PATCH 8 POUCH CRTN	3	Non-Preferred Brand	$90.00	$225.00	Q:8 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN	3	Non-Preferred Brand	$90.00	$225.00	Q:8 /28Days
VIVELLE-DOT 0.1MG PATCH 8 POUCH CRTN	3	Non-Preferred Brand	$90.00	$225.00	Q:8 /28Days
VIVITROL INJ 380MG	5	Specialty	25%	N/A	P
VIVOTIF BERNA 2B UNIT CAPSULE DELAYED RELEASE	2	Preferred Brand	$44.00	$88.00	None
VOLTAREN 0.1% EYE DROPS	2	Preferred Brand	$44.00	$88.00	Q:5 /30Days
VOLTAREN 75MG TABLET EC	2	Preferred Brand	$44.00	$88.00	None
VOSPIRE ER 4MG TABLET SR 12HR	2	Preferred Brand	$44.00	$88.00	None
VOSPIRE ER 8MG TABLET SR 12HR	2	Preferred Brand	$44.00	$88.00	None
VYTORIN 10/10MG TABLET (1000 CT)	2	Preferred Brand	$44.00	$88.00	None
VYTORIN 10/20MG TABLET (1000 CT)	2	Preferred Brand	$44.00	$88.00	None
VYTORIN 10/40MG TABLET (500 CT)	2	Preferred Brand	$44.00	$88.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VYTORIN 10/80MG TABLET 2500 BOT	2	Preferred Brand	$44.00	$88.00	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Health Net Orange Option 1 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).
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 $295 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- 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 October 2009 )

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.