2012 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Premier (PDP) (S5810-198-0)
Benefit Details
|
The Aetna Medicare Rx Premier (PDP) (S5810-198-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 28 which includes: AZ
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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 |
VALACYCLOVIR 1000 MG ORAL TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VALCYTE 450MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VALPROATE SOD 500MG/5ML VL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
VALPROIC ACID 250MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VALPROIC ACID SYRUP USP 250MG 16 FL OZ BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Valturna 150; 160mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
Valturna 300; 320mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
VANCOCIN HCL 125MG PULVULE |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VANCOCIN HCL 250MG PULVULE |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANCOMYCIN HCL 125 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
VANCOMYCIN HCL 250 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
VANCOMYCIN HYDROCHLORIDE INJECTION (STERILE) |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Vandetanib 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
Vandetanib 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
VAQTA 25 UNITS/0.5ML VIAL |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VELCADE 3.5MG VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Velivet Triphasic Regimen 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VENLAFAXINE HCL 100MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:3 /1Days |
VENLAFAXINE HCL 25MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:3 /1Days |
VENLAFAXINE HCL 37.5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:4 /1Days |
VENLAFAXINE HCL 50MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:6 /1Days |
VENLAFAXINE HCL 75MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:5 /1Days |
VENLAFAXINE HCL ER TAB 225 MG |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:1 /1Days |
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:2 /1Days |
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:1 /1Days |
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:2 /1Days |
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:1 /1Days |
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:1 /1Days |
VENTOLIN HFA 90MCG INHALER |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VERAPAMIL 120MG CAP PELLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL 180MG CAP PELLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL 2.5MG/ML AMPUL |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL 240MG CAP PELLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL 40MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL ER 180 MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL HCL 120MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VERAPAMIL HCL 80MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Verapamil Hydrochloride 120mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTEN |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
VEREGEN 15% OINTMENT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VERIPRED 20 ORAL SOLUTION 20MG/5ML 8 FL OZ BOT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VESICARE 10MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
VESICARE 5MG TABLET (90 CT) |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
VESTURA 3 MG-0.02 MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VFEND 200MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P |
VFEND 40MG/ML SUSPENSION |
5 |
Specialty Tier Drugs |
33% | 33% | P |
VFEND 50MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P |
VFEND IV 200MG VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Vibativ 250mg/1 10 CONTAINER in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 CONT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIBRAMYCIN 50MG/5ML SYRUP |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
Vicodin 500; 5mg/1; mg/1 100 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:8 /1Days |
VICODIN ES TABLET 7.5-750 |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:5 /1Days |
VICODIN HP TABLET 10-660 |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:6 /1Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:2 /1Days |
VICTRELIS 200mg/1 4 TRAY in 1 CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE in 1 BOTTLE |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:12 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VIDEX 2GM PEDIATRIC TUBEX |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:7 /1Days |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier Drugs |
33% | 33% | P S Q:6 /1Days |
VIGAMOX 0.5% EYE DROPS |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIIBRYD 1 KIT in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:1 /1Days |
VIIBRYD 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:1 /1Days |
VIIBRYD 20mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:1 /1Days |
VIIBRYD 40mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:1 /1Days |
VIMOVO 375-20 MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:2 /1Days |
VIMOVO 500-20 MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P Q:40 /1Days |
Vimpat 100mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P S Q:2 /1Days |
Vimpat 10mg/mL 10 VIAL, GLASS in 1 CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P S Q:40 /1Days |
Vimpat 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P S Q:2 /1Days |
Vimpat 200mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P S Q:2 /1Days |
Vimpat 50mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P S Q:6 /1Days |
VINBLASTINE SULF 10MG VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
VINCRISTINE 1MG/ML VIAL |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIRACEPT 50MG/GM ORAL POWDER |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VIRAMUNE 200MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIRAZOLE 6GM VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VIREAD 150 MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIREAD 200 MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIREAD 250 MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIREAD 300MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIREAD POWDER |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VISTIDE 75MG/ML VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VIVACTIL 10MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VIVACTIL 5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Vivelle Dot 0.025mg/d 3 PACKET in 1 CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:8 /28Days |
Vivelle Dot 0.0375mg/d 3 PACKET in 1 CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:8 /28Days |
Vivelle Dot 0.05mg/d 3 PACKET in 1 CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 P |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:8 /28Days |
Vivelle Dot 0.1mg/d 3 PACKET in 1 CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 PA |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:8 /28Days |
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:8 /28Days |
Voltaren 10mg/g |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:34 /1Days |
Voriconazole 200mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Voriconazole 50mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VORICONAZOLE INJ 200MG |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
VOSPIRE ER 4MG TABLET SR 12HR |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VOSPIRE ER 8MG TABLET SR 12HR |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
VOTRIENT 200mg/1 120 TABLET, FILM COATED in 1 BOTTLE |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:4 /1Days |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier Drugs |
33% | 33% | None |
VYTORIN 10/10MG TABLET (1000 CT) |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
VYTORIN 10/20MG TABLET (1000 CT) |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
VYTORIN 10/40MG TABLET (500 CT) |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
VYTORIN 10/80MG TABLET 2500 BOT |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |