2014 Medicare Part D Plan Formulary Information |
PacificSource Medicare Essentials Rx 14 (HMO) (H3864-014-0)
Benefit Details
|
The PacificSource Medicare Essentials Rx 14 (HMO) (H3864-014-0) Formulary Drugs Starting with the Letter V in SHERMAN County, OR: CMS MA Region 23 which includes: OR Plan Monthly Premium: $88.00 Deductible: $0 |
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 |
$45.00 | $135.00 | None |
VALACYCLOVIR 1000 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VALCYTE 450MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VALCYTE FOR ORAL SOLUTION 50MG/ML |
5 |
Specialty Tier |
33% | N/A | None |
Valproate Sodium 100mg/mL 10 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VANCOMYCIN HCL 125 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
VANCOMYCIN HCL 250 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VANOS 0.1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VAQTA 25 UNITS/0.5ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VELCADE 3.5MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VELTIN 10; 0.25mg/g; mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
VENLAFAXINE HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HCL 25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HCL 37.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HCL 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL 75MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HCL ER TAB 225 MG |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VENTOLIN HFA 90MCG INHALER |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:36 /30Days |
VERAMYST 27.5MCG SPRAY SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:10 /30Days |
VERAPAMIL 120MG CAP PELLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 180MG CAP PELLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL 2.5MG/ML AMPUL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL 240MG CAP PELLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL 40MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL ER 120 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL ER 180 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL HCL 120MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL HCL 80MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
VEREGEN 15% OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VERIPRED 20 ORAL SOLUTION 20MG/5ML 8 FL OZ BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VERSACLOZ 50 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | None |
VESICARE 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VESICARE 5MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VEXOL 1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VFEND 40MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | None |
VIBRAMYCIN 25MG/5ML SUSP |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIBRAMYCIN 50MG/5ML SYRUP |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
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 |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days |
VICTRELIS 200mg/1 4 TRAY per CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
5 |
Specialty Tier |
33% | N/A | P |
VIDEX 2GM PEDIATRIC TUBEX |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIDEX EC 125MG CAPSULE SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIDEX EC 200MG CAPSULE SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIDEX EC 250MG CAPSULE SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIDEX EC 400MG CAPSULE SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
5 |
Specialty Tier |
33% | N/A | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
33% | N/A | None |
VIGAMOX 0.5% EYE DROPS |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIIBRYD 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VIMOVO 375-20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VIMOVO 500-20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VINBLASTINE 1 MG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
VIOKACE 10,440-39,150 UNITS TB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIOKACE 20,880-78,300 UNITS TB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIRAMUNE 200MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIRAMUNE XR 100 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VIREAD 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
VIREAD 200 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
VIREAD 250 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
VIREAD 300MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
VIREAD POWDER |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VISTIDE 75MG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Vivelle Dot 0.025mg/d 3 PACKET per CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Vivelle Dot 0.0375mg/d 3 PACKET per CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Vivelle Dot 0.05mg/d 3 PACKET per CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 P |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Vivelle Dot 0.1mg/d 3 PACKET per CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 PA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
5 |
Specialty Tier |
33% | N/A | None |
VOLTAREN 1% GEL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | None |
Voriconazole 40 mg/ml susp |
5 |
Specialty Tier |
33% | N/A | None |
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | None |
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
33% | N/A | P |
VYTORIN 10/40MG TABLET (500 CT) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
VYTORIN 10/80MG TABLET 2500 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYVANSE 30MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VYVANSE 40MG CAPSULE 100 EA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VYVANSE 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VYVANSE 70MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VYVANSE CAPSULES 20MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
VYVANSE CAPSULES 60MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |