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MedicareBlue Rx Standard (PDP) (S5743-001-0)
Tier 1 (1626)
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Tier 4 (212)

Requires Prior Authorization:
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2010 Medicare Part D Plan Formulary Information
MedicareBlue Rx Standard (PDP) (S5743-001-0)
Benefit Details  
The MedicareBlue Rx Standard (PDP) (S5743-001-0)
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
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
VAGIFEM 25MCG VAGINAL TABLET   2 Level 2: Covered Preferred Brand 22%22%None
VALCYTE 450MG TABLET   4 Covered Specialty 25%25%None
VALPROATE SOD 500MG/5ML VL   1 Level 1: Covered Generics 10%10%None
VALPROIC ACID 250MG CAPSULE   1 Level 1: Covered Generics 10%10%None
VALPROIC ACID SYRUP USP 250MG 16 FL OZ BOT   1 Level 1: Covered Generics 10%10%None
VALTREX 1GM CAPLET (90 CT)   3 Level 3: Covered Brand 50%50%None
VALTREX 500MG TABLET   3 Level 3: Covered Brand 50%50%None
VANACET 5/500 TABLET   1 Level 1: Covered Generics 10%10%None
VANCOCIN HCL 125MG PULVULE   4 Covered Specialty 25%25%None
VANCOCIN HCL 1G/200ML BAG   3 Level 3: Covered Brand 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VANCOCIN HCL 250MG PULVULE   4 Covered Specialty 25%25%None
VANDAZOLE 0.75% GEL WITH APPLICATOR   1 Level 1: Covered Generics 10%10%None
VAQTA 25 UNITS/0.5ML VIAL   3 Level 3: Covered Brand 50%50%None
VARIVAX VACCINE W/DILUENT   3 Level 3: Covered Brand 50%50%None
VECTIBIX SINGLE USE VIAL INJECTION 200MG/10ML   4 Covered Specialty 25%25%None
VEETIDS 125MG/5ML ORAL SUSP   1 Level 1: Covered Generics 10%10%None
VEETIDS 250MG TABLET   1 Level 1: Covered Generics 10%10%None
VEETIDS 500MG TABLET   1 Level 1: Covered Generics 10%10%None
VELCADE 3.5MG VIAL   4 Covered Specialty 25%25%None
VELIVET TABLET TRIPHASIC 28 (7BEIGE+7ORANGE+7PINK)   1 Level 1: Covered Generics 10%10%None
VENLAFAXINE HCL 100MG TABLET   1 Level 1: Covered Generics 10%10%S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VENLAFAXINE HCL 25MG TABLET   1 Level 1: Covered Generics 10%10%S
VENLAFAXINE HCL 37.5MG TABLET   1 Level 1: Covered Generics 10%10%S
VENLAFAXINE HCL 50MG TABLET   1 Level 1: Covered Generics 10%10%S
VENLAFAXINE HCL 75MG TABLET   1 Level 1: Covered Generics 10%10%S
VENLAFAXINE HCL ER TAB   2 Level 2: Covered Preferred Brand 22%22%S
VENLAFAXINE HCL ER TAB 225 MG   2 Level 2: Covered Preferred Brand 22%22%S
VENLAFAXINE HCL ER TAB 37.5 MG   2 Level 2: Covered Preferred Brand 22%22%S
VENLAFAXINE HCL ER TAB 75 MG   2 Level 2: Covered Preferred Brand 22%22%S
VENTOLIN HFA 90MCG INHALER   2 Level 2: Covered Preferred Brand 22%22%Q:36
/30Days
VERAPAMIL 120MG CAP PELLET   1 Level 1: Covered Generics 10%10%None
VERAPAMIL 120MG TABLET SA   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VERAPAMIL 180MG CAP PELLET   1 Level 1: Covered Generics 10%10%None
VERAPAMIL 240MG CAP PELLET   1 Level 1: Covered Generics 10%10%None
VERAPAMIL 40MG TABLET   1 Level 1: Covered Generics 10%10%None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   1 Level 1: Covered Generics 10%10%None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   1 Level 1: Covered Generics 10%10%None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS   1 Level 1: Covered Generics 10%10%None
VERAPAMIL HCL 120MG TABLET   1 Level 1: Covered Generics 10%10%None
VERAPAMIL HCL 18OMG ER TABLET   1 Level 1: Covered Generics 10%10%None
VERAPAMIL HCL 240MG TABLET SA   1 Level 1: Covered Generics 10%10%None
VERAPAMIL HCL 80MG TABLET   1 Level 1: Covered Generics 10%10%None
VESICARE 10MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VESICARE 5MG TABLET (90 CT)   2 Level 2: Covered Preferred Brand 22%22%Q:30
/30Days
VFEND 200MG TABLET   4 Covered Specialty 25%25%P
VFEND 40MG/ML SUSPENSION   4 Covered Specialty 25%25%P
VFEND 50MG TABLET   4 Covered Specialty 25%25%P
VFEND IV 200MG VIAL   4 Covered Specialty 25%25%P
VICODIN HP TABLET 10-660   1 Level 1: Covered Generics 10%10%None
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU   4 Covered Specialty 25%25%None
VIDEX 2GM PEDIATRIC TUBEX   3 Level 3: Covered Brand 50%50%None
VIGAMOX 0.5% EYE DROPS   2 Level 2: Covered Preferred Brand 22%22%None
VIMPAT INJECTION 10MG/ML 10 X 20ML VIALGL   3 Level 3: Covered Brand 50%50%S
VIMPAT TABLETS 100MG 60 BOTPL   3 Level 3: Covered Brand 50%50%S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIMPAT TABLETS 150MG 60 BOTPL   3 Level 3: Covered Brand 50%50%S
VIMPAT TABLETS 200MG 60 BOTPL   3 Level 3: Covered Brand 50%50%S
VIMPAT TABLETS 50MG 60 BOTPL   3 Level 3: Covered Brand 50%50%S
VINBLASTINE SULF 10MG VIAL   3 Level 3: Covered Brand 50%50%P
VINCRISTINE 1MG/ML VIAL   1 Level 1: Covered Generics 10%10%None
VINCRISTINE 1MG/ML VIAL   1 Level 1: Covered Generics 10%10%None
VINORELBINE 10MG/ML VIAL 5ML VIAL   1 Level 1: Covered Generics 10%10%None
VIRACEPT 250MG TABLET   3 Level 3: Covered Brand 50%50%None
VIRACEPT 50MG/GM ORAL POWDER   3 Level 3: Covered Brand 50%50%None
VIRACEPT 625MG TABLET   3 Level 3: Covered Brand 50%50%None
VIRAMUNE 200MG TABLET   3 Level 3: Covered Brand 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIRAMUNE 50MG/5ML SUSP   3 Level 3: Covered Brand 50%50%None
VIREAD 300MG TABLET   3 Level 3: Covered Brand 50%50%None
VISTIDE 75MG/ML VIAL   4 Covered Specialty 25%25%None
VIVELLE-DOT 0.025MG PATCH   2 Level 2: Covered Preferred Brand 22%22%None
VIVELLE-DOT 0.0375MG PATCH 8 POUCH CRTN   2 Level 2: Covered Preferred Brand 22%22%None
VIVELLE-DOT 0.05MG PATCH 8 POUCH CRTN   2 Level 2: Covered Preferred Brand 22%22%None
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN   2 Level 2: Covered Preferred Brand 22%22%None
VIVELLE-DOT 0.1MG PATCH 8 POUCH CRTN   2 Level 2: Covered Preferred Brand 22%22%None
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL   4 Covered Specialty 25%25%None
VIVOTIF BERNA 2B UNIT CAPSULE DELAYED RELEASE   3 Level 3: Covered Brand 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D MedicareBlue Rx Standard (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).

  • 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 $310 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 $2830) 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 2010 )

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.