2013 Medicare Part D Plan Formulary Information |
BlueRx Option II (PDP) (S1030-001-0)
Benefit Details
|
The BlueRx Option II (PDP) (S1030-001-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 12 which includes: AL TN
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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 |
VAGIFEM 10 MCG VAGINAL TAB |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
VALACYCLOVIR 1000 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VALCYTE 450MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
VALCYTE FOR ORAL SOLUTION 50MG/ML |
5 |
Specialty Tier |
33% | 33% | None |
Valproate Sodium 100mg/mL 10 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VALSARTAN-HCTZ 160-12.5 MG TAB |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TAB |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN-HCTZ 320-12.5 MG TAB |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TAB |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TAB |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
VALTREX 1GM CAPLET (90 CT) |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VALTREX 500MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VANCOCIN HCL 125MG PULVULE |
5 |
Specialty Tier |
33% | 33% | None |
VANCOCIN HCL 250MG PULVULE |
5 |
Specialty Tier |
33% | 33% | None |
VANCOMYCIN HCL 125 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
VANCOMYCIN HCL 250 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
VANCOMYCIN HYDROCHLORIDE INJECTION (STERILE) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VAQTA 25 UNITS/0.5ML VIAL |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VARIVAX VACCINE W/DILUENT |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VASERETIC 10-25 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VASOTEC 10 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VASOTEC 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VASOTEC 20 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VASOTEC 5MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | 33% | None |
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
VELCADE 3.5MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
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 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VENLAFAXINE HCL 100MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
VENLAFAXINE HCL 25MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
VENLAFAXINE HCL 37.5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
VENLAFAXINE HCL 50MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
VENLAFAXINE HCL 75MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days |
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 |
$8.00 | $16.00 | Q:90 /30Days |
VENTOLIN HFA 90MCG INHALER |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:36 /30Days |
VERAPAMIL 120MG CAP PELLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL 180MG CAP PELLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL 240MG CAP PELLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL 40MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL ER 120 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL ER 180 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL HCL 120MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL HCL 80MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
VERELAN 120MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VERELAN 180MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VERELAN 240MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VERELAN 360MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VERELAN PM 100MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VERELAN PM 200MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VERELAN PM 300MG CAP PELLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VESICARE 10MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | 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) |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:30 /30Days |
VESTURA 3 MG-0.02 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VFEND 40MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | 33% | P |
VFEND IV 200MG VIAL |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | P |
VIBRAMYCIN 100MG CAPSULE |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VICOPROFEN 200/7.5 TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:150 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$40.00 | $80.00 | S Q:9 /30Days |
VICTRELIS 200mg/1 4 TRAY in 1 CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE in 1 BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
5 |
Specialty Tier |
33% | 33% | None |
VIDEX 2GM PEDIATRIC TUBEX |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:1200 /30Days |
VIDEX EC 125MG CAPSULE SA |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIDEX EC 200MG CAPSULE SA |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIDEX EC 250MG CAPSULE SA |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIDEX EC 400MG CAPSULE SA |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VIGAMOX 0.5% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
VIIBRYD 1 KIT in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S Q:30 /30Days |
VIMOVO 375-20 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIMOVO 500-20 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:60 /30Days |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S |
Vimpat 10mg/mL 10 VIAL, GLASS in 1 CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | S |
VINBLASTINE SULF 10MG VIAL |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | P |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIOKACE 10,440-39,150 UNITS TB |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VIOKACE 20,880-78,300 UNITS TB |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VIRACEPT 250MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:270 /30Days |
VIRACEPT 625MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:120 /30Days |
VIRAMUNE 200MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:60 /30Days |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:1200 /30Days |
VIRAMUNE XR 100 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:90 /30Days |
VIREAD 150 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIREAD 200 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIREAD 250 MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIREAD 300MG TABLET |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:30 /30Days |
VIREAD POWDER |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:240 /30Days |
VIROPTIC 1% EYE DROPS |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VISTIDE 75MG/ML VIAL |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | 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 |
$40.00 | $80.00 | None |
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 |
$40.00 | $80.00 | None |
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 |
$40.00 | $80.00 | None |
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 |
$40.00 | $80.00 | None |
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
5 |
Specialty Tier |
33% | 33% | None |
VOLTAREN 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Voltaren 10mg/g |
3 |
Preferred Brand |
$40.00 | $80.00 | S Q:1000 /30Days |
VOLTAREN-XR 100MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None |
VORICONAZOLE 200 MG VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | P |
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | P |
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
33% | 33% | None |
VYTORIN 10/10MG TABLET (1000 CT) |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:45 /30Days |
VYTORIN 10/20MG TABLET (1000 CT) |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:45 /30Days |
VYTORIN 10/40MG TABLET (500 CT) |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:45 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:30 /30Days |