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Community CCRx Basic (PDP) (S5803-077-0)
Tier 1 (1399)
Tier 2 (779)
Tier 3 (521)
Tier 4 (320)

Requires Prior Authorization:
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Uses Step Therapy:
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Has Quantity Limits:
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2012 Medicare Part D Plan Formulary Information
Community CCRx Basic (PDP) (S5803-077-0)
Benefit Details           
The Community CCRx Basic (PDP) (S5803-077-0)
Formulary Drugs Starting with the Letter V

in CMS PDP Region 8 which includes: NC
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 10 MCG VAGINAL TAB   2 Preferred Brand Drugs 25%N/ANone
VALACYCLOVIR 1000 MG ORAL TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
VALACYCLOVIR 500 MG ORAL TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
VALCYTE 450MG TABLET   4 Specialty Tier Drugs 25%N/AP
VALCYTE FOR ORAL SOLUTION 50MG/ML   4 Specialty Tier Drugs 25%N/AP
VALPROATE SOD 500MG/5ML VL   1 Generic Drugs $2.00N/ANone
VALPROIC ACID 250MG CAPSULE   1 Generic Drugs $2.00N/ANone
VALPROIC ACID SYRUP USP 250MG 16 FL OZ BOT   1 Generic Drugs $2.00N/ANone
Valturna 150; 160mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Valturna 300; 320mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VANCOMYCIN HCL 125 MG CAPSULE   4 Specialty Tier Drugs 25%N/ANone
VANCOMYCIN HCL 250 MG CAPSULE   4 Specialty Tier Drugs 25%N/ANone
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )   2 Preferred Brand Drugs 25%N/AP
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   2 Preferred Brand Drugs 25%N/AP
VANCOMYCIN HYDROCHLORIDE INJECTION (STERILE)   2 Preferred Brand Drugs 25%N/AP
VANDAZOLE 0.75% GEL WITH APPLICATOR   1 Generic Drugs $2.00N/ANone
Vandetanib 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC   4 Specialty Tier Drugs 25%N/AP Q:60
/30Days
Vandetanib 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC   4 Specialty Tier Drugs 25%N/AP Q:30
/30Days
VAQTA 25 UNITS/0.5ML VIAL   2 Preferred Brand Drugs 25%N/ANone
VARIVAX VACCINE W/DILUENT   2 Preferred Brand Drugs 25%N/ANone
VELCADE 3.5MG VIAL   4 Specialty Tier Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Velivet Triphasic Regimen 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK   1 Generic Drugs $2.00N/AQ:28
/28Days
VENLAFAXINE HCL 100MG TABLET   1 Generic Drugs $2.00N/ANone
VENLAFAXINE HCL 25MG TABLET   1 Generic Drugs $2.00N/ANone
VENLAFAXINE HCL 37.5MG TABLET   1 Generic Drugs $2.00N/ANone
VENLAFAXINE HCL 50MG TABLET   1 Generic Drugs $2.00N/ANone
VENLAFAXINE HCL 75MG TABLET   1 Generic Drugs $2.00N/ANone
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   1 Generic Drugs $2.00N/AQ:60
/30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   1 Generic Drugs $2.00N/AQ:30
/30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   1 Generic Drugs $2.00N/AQ:30
/30Days
VERAMYST 27.5MCG SPRAY SUSPENSION   2 Preferred Brand Drugs 25%N/AQ:20
/30Days
VERAPAMIL 120MG CAP PELLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERAPAMIL 180MG CAP PELLET   1 Generic Drugs $2.00N/ANone
VERAPAMIL 240MG CAP PELLET   1 Generic Drugs $2.00N/ANone
VERAPAMIL 40MG TABLET   1 Generic Drugs $2.00N/ANone
VERAPAMIL ER 180 MG TABLET   1 Generic Drugs $2.00N/ANone
VERAPAMIL HCL 120MG TABLET   1 Generic Drugs $2.00N/ANone
VERAPAMIL HCL 80MG TABLET   1 Generic Drugs $2.00N/ANone
Verapamil Hydrochloride 120mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTEN   1 Generic Drugs $2.00N/ANone
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Generic Drugs $2.00N/ANone
VESTURA 3 MG-0.02 MG TABLET   2 Preferred Brand Drugs 25%N/AQ:28
/28Days
VFEND 40MG/ML SUSPENSION   4 Specialty Tier Drugs 25%N/AQ:450
/30Days
VIBRAMYCIN 50MG/5ML SYRUP   2 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VICTOZA 3-PAK 18 MG/3 ML PEN   2 Preferred Brand Drugs 25%N/AQ:9
/30Days
VICTRELIS 200mg/1 4 TRAY in 1 CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE in 1 BOTTLE   4 Specialty Tier Drugs 25%N/AP Q:360
/30Days
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU   4 Specialty Tier Drugs 25%N/AP
VIDEX 2GM PEDIATRIC TUBEX   3 Non-Preferred Brand Drugs 47%N/ANone
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]   4 Specialty Tier Drugs 25%N/AP Q:180
/30Days
VIGABATRIN 500 MG ORAL TABLET [SABRIL]   4 Specialty Tier Drugs 25%N/AP Q:180
/30Days
VIGAMOX 0.5% EYE DROPS   2 Preferred Brand Drugs 25%N/ANone
VIIBRYD 1 KIT in 1 BLISTER PACK   2 Preferred Brand Drugs 25%N/ANone
VIIBRYD 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
VIIBRYD 20mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
VIIBRYD 40mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIMPAT 10 MG/ML SOLUTION   3 Non-Preferred Brand Drugs 47%N/AQ:1200
/30Days
Vimpat 100mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Non-Preferred Brand Drugs 47%N/AQ:60
/30Days
Vimpat 10mg/mL 10 VIAL, GLASS in 1 CARTON / 20 mL in 1 VIAL, GLASS   3 Non-Preferred Brand Drugs 47%N/AQ:1200
/30Days
Vimpat 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Non-Preferred Brand Drugs 47%N/AQ:60
/30Days
Vimpat 200mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Non-Preferred Brand Drugs 47%N/AQ:60
/30Days
Vimpat 50mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Non-Preferred Brand Drugs 47%N/AQ:60
/30Days
VIRACEPT 250MG TABLET   4 Specialty Tier Drugs 25%N/ANone
VIRACEPT 50MG/GM ORAL POWDER   3 Non-Preferred Brand Drugs 47%N/ANone
VIRACEPT 625MG TABLET   4 Specialty Tier Drugs 25%N/ANone
VIRAMUNE 200MG TABLET   3 Non-Preferred Brand Drugs 47%N/ANone
VIRAMUNE 50MG/5ML SUSP   3 Non-Preferred Brand Drugs 47%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIREAD 150 MG TABLET   2 Preferred Brand Drugs 25%N/ANone
VIREAD 200 MG TABLET   2 Preferred Brand Drugs 25%N/ANone
VIREAD 250 MG TABLET   2 Preferred Brand Drugs 25%N/ANone
VIREAD 300MG TABLET   2 Preferred Brand Drugs 25%N/ANone
VIREAD POWDER   2 Preferred Brand Drugs 25%N/ANone
VISTIDE 75MG/ML VIAL   4 Specialty Tier Drugs 25%N/AP
VIVAGLOBIN SOL 160MG/ML 10ML VIAL   4 Specialty Tier Drugs 25%N/AP
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 Non-Preferred Brand Drugs 47%N/AQ: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 Non-Preferred Brand Drugs 47%N/AQ: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 Non-Preferred Brand Drugs 47%N/AQ: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 Non-Preferred Brand Drugs 47%N/AQ: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 Drugs 47%N/AQ:8
/28Days
Voltaren 10mg/g   2 Preferred Brand Drugs 25%N/AQ:500
/30Days
Voriconazole 200mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   4 Specialty Tier Drugs 25%N/AQ:120
/30Days
Voriconazole 50mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   4 Specialty Tier Drugs 25%N/AQ:120
/30Days
VOTRIENT 200mg/1 120 TABLET, FILM COATED in 1 BOTTLE   4 Specialty Tier Drugs 25%N/AP Q:120
/30Days
VPRIV INJECTION SOLUTION 2.5 MG/ML   4 Specialty Tier Drugs 25%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Community CCRx Basic (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 $320 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 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 September 2012 )

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.