Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
First Health Part D Premier (PDP) (S5768-007-0) Benefit Details
The First Health Part D Premier (PDP) (S5768-007-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 4 which includes: NJ
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 10 MCG VAGINAL TAB	3	Non-Preferred Brand Drugs	41%	41%	None
VALACYCLOVIR 1000 MG ORAL TABLET	3	Non-Preferred Brand Drugs	41%	41%	Q:30 /30Days
VALACYCLOVIR 500 MG ORAL TABLET	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
VALCYTE 450MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
Valproate Sodium 100mg/mL 10 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE	1	Preferred Generic Drugs	$1.00	$3.00	None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE	1	Preferred Generic Drugs	$1.00	$3.00	None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE	1	Preferred Generic Drugs	$1.00	$3.00	None
VALSARTAN-HCTZ 160-12.5 MG TAB	1	Preferred Generic Drugs	$1.00	$3.00	Q:30 /30Days
VALSARTAN-HCTZ 160-25 MG TAB	1	Preferred Generic Drugs	$1.00	$3.00	Q:30 /30Days
VALSARTAN-HCTZ 320-12.5 MG TAB	1	Preferred Generic Drugs	$1.00	$3.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VALSARTAN-HCTZ 320-25 MG TAB	1	Preferred Generic Drugs	$1.00	$3.00	Q:30 /30Days
VALSARTAN-HCTZ 80-12.5 MG TAB	1	Preferred Generic Drugs	$1.00	$3.00	Q:30 /30Days
VANCOMYCIN HCL 125 MG CAPSULE	3	Non-Preferred Brand Drugs	41%	41%	P Q:56 /14Days
VANCOMYCIN HCL 250 MG CAPSULE	3	Non-Preferred Brand Drugs	41%	41%	P Q:40 /10Days
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )	1	Preferred Generic Drugs	$1.00	$3.00	P
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA	1	Preferred Generic Drugs	$1.00	$3.00	P
VANCOMYCIN HYDROCHLORIDE INJECTION (STERILE)	1	Preferred Generic Drugs	$1.00	$3.00	P
VANDAZOLE 0.75% GEL WITH APPLICATOR	1	Preferred Generic Drugs	$1.00	$3.00	None
VAQTA 25 UNITS/0.5ML VIAL	3	Non-Preferred Brand Drugs	41%	41%	None
VARIVAX VACCINE W/DILUENT	2	Preferred Brand Drugs	25%	25%	None
VASCEPA 1 GM CAPSULE	2	Preferred Brand Drugs	25%	25%	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VELCADE 3.5MG VIAL	3	Non-Preferred Brand Drugs	41%	41%	P
Velivet Triphasic Regimen 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK	1	Preferred Generic Drugs	$1.00	$3.00	None
VENLAFAXINE HCL 100MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VENLAFAXINE HCL 25MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VENLAFAXINE HCL 37.5MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VENLAFAXINE HCL 50MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VENLAFAXINE HCL 75MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VENLAFAXINE HCL ER TAB 225 MG	3	Non-Preferred Brand Drugs	41%	41%	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Preferred Generic Drugs	$1.00	$3.00	Q:90 /30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Preferred Generic Drugs	$1.00	$3.00	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Preferred Generic Drugs	$1.00	$3.00	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	3	Non-Preferred Brand Drugs	41%	41%	Q:90 /30Days
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE	3	Non-Preferred Brand Drugs	41%	41%	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE	3	Non-Preferred Brand Drugs	41%	41%	Q:30 /30Days
Ventavis 0.01mg/mL	3	Non-Preferred Brand Drugs	41%	41%	P
Ventavis 0.02mg/mL	3	Non-Preferred Brand Drugs	41%	41%	P
VENTOLIN HFA 90MCG INHALER	2	Preferred Brand Drugs	25%	25%	Q:36 /30Days
VERAPAMIL 120MG CAP PELLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL 180MG CAP PELLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL 2.5MG/ML AMPUL	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL 240MG CAP PELLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL 40MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL ER 120 MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL ER 180 MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL HCL 120MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
VERAPAMIL HCL 80MG TABLET	1	Preferred Generic Drugs	$1.00	$3.00	None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	1	Preferred Generic Drugs	$1.00	$3.00	None
VEREGEN 15% OINTMENT	3	Non-Preferred Brand Drugs	41%	41%	Q:15 /30Days
VESICARE 10MG TABLET	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
VESICARE 5MG TABLET (90 CT)	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VESTURA 3 MG-0.02 MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VEXOL 1% EYE DROPS	3	Non-Preferred Brand Drugs	41%	41%	None
VFEND 40MG/ML SUSPENSION	3	Non-Preferred Brand Drugs	41%	41%	None
VIBRAMYCIN 50MG/5ML SYRUP	3	Non-Preferred Brand Drugs	41%	41%	None
VICTOZA 3-PAK 18 MG/3 ML PEN	2	Preferred Brand Drugs	25%	25%	Q:9 /30Days
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU	3	Non-Preferred Brand Drugs	41%	41%	P
VIDEX 2GM PEDIATRIC TUBEX	3	Non-Preferred Brand Drugs	41%	41%	None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]	3	Non-Preferred Brand Drugs	41%	41%	P
VIGABATRIN 500 MG ORAL TABLET [SABRIL]	3	Non-Preferred Brand Drugs	41%	41%	P
VIGAMOX 0.5% EYE DROPS	3	Non-Preferred Brand Drugs	41%	41%	Q:3 /30Days
VIIBRYD 1 KIT in 1 BLISTER PACK	2	Preferred Brand Drugs	25%	25%	Q:30 /365Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
VIMOVO 375-20 MG TABLET	2	Preferred Brand Drugs	25%	25%	Q:60 /30Days
VIMOVO 500-20 MG TABLET	2	Preferred Brand Drugs	25%	25%	Q:60 /30Days
VIMPAT 10 MG/ML SOLUTION	3	Non-Preferred Brand Drugs	41%	41%	None
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
Vimpat 10mg/mL 10 VIAL, GLASS in 1 CARTON / 20 mL in 1 VIAL, GLASS	3	Non-Preferred Brand Drugs	41%	41%	None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIRACEPT 250MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VIRACEPT 625MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand Drugs	41%	41%	None
VIRAMUNE 50MG/5ML SUSP	3	Non-Preferred Brand Drugs	41%	41%	None
VIRAMUNE XR 100 MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VIREAD 150 MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VIREAD 200 MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VIREAD 250 MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VIREAD 300MG TABLET	3	Non-Preferred Brand Drugs	41%	41%	None
VIREAD POWDER	3	Non-Preferred Brand Drugs	41%	41%	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	Non-Preferred Brand Drugs	41%	41%	Q:8 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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	41%	41%	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	Non-Preferred Brand Drugs	41%	41%	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	Non-Preferred Brand Drugs	41%	41%	Q:8 /28Days
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN	3	Non-Preferred Brand Drugs	41%	41%	Q:8 /28Days
Voltaren 10mg/g	3	Non-Preferred Brand Drugs	41%	41%	Q:1000 /30Days
VORAXAZE 1,000 UNIT VIAL	3	Non-Preferred Brand Drugs	41%	41%	P
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand Drugs	41%	41%	Q:60 /30Days
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand Drugs	41%	41%	P Q:120 /30Days
VYTORIN 10/10MG TABLET (1000 CT)	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
VYTORIN 10/20MG TABLET (1000 CT)	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VYTORIN 10/40MG TABLET (500 CT)	2	Preferred Brand Drugs	25%	25%	Q:30 /30Days
VYTORIN 10/80MG TABLET 2500 BOT	2	Preferred Brand Drugs	25%	25%	P Q:30 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D First Health Part D Premier (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 $325 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 $2970) 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 2013 )

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.