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Blue Rx Plus (PDP) (S5593-002-0)
Tier 1 (666)
Tier 2 (1604)
Tier 3 (502)
Tier 4 (1308)
Tier 5 (426)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Cick on the first letter of your drug name to browse the formulary:

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2014 Medicare Part D Plan Formulary Information
Blue Rx Plus (PDP) (S5593-002-0)
Benefit Details           
The Blue Rx Plus (PDP) (S5593-002-0)
Formulary Drugs Starting with the Letter V
in CMS PDP Region 6 which includes: PA WV
Plan Monthly Premium: $74.30 Deductible: $310 Qualifies for LIS: No
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   4 Non-Preferred Brand 50%50%None
VALACYCLOVIR 1000 MG ORAL TABLET   2 Non-Preferred Generic $11.00$27.50None
VALACYCLOVIR 500 MG ORAL TABLET   2 Non-Preferred Generic $11.00$27.50None
VALCYTE 450MG TABLET   5 Specialty Tier 25%25%None
VALCYTE FOR ORAL SOLUTION 50MG/ML   4 Non-Preferred Brand 50%50%None
Valproate Sodium 100mg/mL 10 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE   2 Non-Preferred Generic $11.00$27.50None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE   2 Non-Preferred Generic $11.00$27.50None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic $11.00$27.50None
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]   1 Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]   1 Preferred Generic $0.00$0.00None
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]   1 Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]   1 Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]   1 Preferred Generic $0.00$0.00None
VALTREX 1GM CAPLET (90 CT)   4 Non-Preferred Brand 50%50%None
VALTREX 500MG TABLET   4 Non-Preferred Brand 50%50%None
VANCOCIN HCL 125MG PULVULE   5 Specialty Tier 25%25%None
VANCOCIN HCL 250MG PULVULE   5 Specialty Tier 25%25%None
VANCOMYCIN HCL 125 MG CAPSULE   5 Specialty Tier 25%25%None
VANCOMYCIN HCL 250 MG CAPSULE   5 Specialty Tier 25%25%None
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )   2 Non-Preferred Generic $11.00$27.50P
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   2 Non-Preferred Generic $11.00$27.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE)   2 Non-Preferred Generic $11.00$27.50P
VANDAZOLE 0.75% GEL WITH APPLICATOR   2 Non-Preferred Generic $11.00$27.50None
VANOS 0.1% CREAM   4 Non-Preferred Brand 50%50%None
VAQTA 25 UNITS/0.5ML VIAL   3 Preferred Brand 25%25%None
VARIVAX VACCINE W/DILUENT   3 Preferred Brand 25%25%None
VASCEPA 1 GM CAPSULE   4 Non-Preferred Brand 50%50%None
VECAMYL 2.5 MG TABLET   4 Non-Preferred Brand 50%50%None
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE   4 Non-Preferred Brand 50%50%None
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE   4 Non-Preferred Brand 50%50%None
VELCADE 3.5MG VIAL   5 Specialty Tier 25%25%None
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   2 Non-Preferred Generic $11.00$27.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VELPHORO 500 MG CHEWABLE TAB   5 Specialty Tier 25%25%None
VENLAFAXINE HCL 100MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HCL 25MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HCL 37.5MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HCL 50MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HCL 75MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HCL ER TAB 225 MG   4 Non-Preferred Brand 50%50%None
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE   2 Non-Preferred Generic $11.00$27.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $11.00$27.50None
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE   2 Non-Preferred Generic $11.00$27.50None
Ventavis 0.01mg/mL   5 Specialty Tier 25%25%P
Ventavis 0.02mg/mL   5 Specialty Tier 25%25%P
VENTOLIN HFA 90MCG INHALER   3 Preferred Brand 25%25%None
VERAMYST 27.5MCG SPRAY SUSPENSION   4 Non-Preferred Brand 50%50%None
VERAPAMIL 120MG CAP PELLET   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL 180MG CAP PELLET   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL 2.5MG/ML AMPUL   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL 240MG CAP PELLET   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL 40MG TABLET   2 Non-Preferred Generic $11.00$27.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL ER 120 MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL ER 180 MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL HCL 120MG TABLET   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   2 Non-Preferred Generic $11.00$27.50None
VERAPAMIL HCL 80MG TABLET   2 Non-Preferred Generic $11.00$27.50None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic $11.00$27.50None
VEREGEN 15% OINTMENT   4 Non-Preferred Brand 50%50%None
VERIPRED 20 ORAL SOLUTION 20MG/5ML 8 FL OZ BOT   2 Non-Preferred Generic $11.00$27.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VERSACLOZ 50 MG/ML SUSPENSION   3 Preferred Brand 25%25%None
VESICARE 10MG TABLET   3 Preferred Brand 25%25%None
VESICARE 5MG TABLET (90 CT)   3 Preferred Brand 25%25%None
Vestura 3 mg-0.02 mg tablet   2 Non-Preferred Generic $11.00$27.50None
VFEND 200MG TABLET   5 Specialty Tier 25%25%None
VFEND 40MG/ML SUSPENSION   5 Specialty Tier 25%25%None
VFEND 50MG TABLET   5 Specialty Tier 25%25%None
VFEND IV 200MG VIAL   4 Non-Preferred Brand 50%50%None
VICODIN 5-300 MG TABLET   2 Non-Preferred Generic $11.00$27.50Q:403
/31Days
VICODIN ES 7.5-300 MG TABLET   2 Non-Preferred Generic $11.00$27.50Q:403
/31Days
VICODIN HP 10-300 MG TABLET   2 Non-Preferred Generic $11.00$27.50Q:403
/31Days
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 25%25%None
VICTRELIS 200mg/1 4 TRAY per CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE BOTTLE   5 Specialty Tier 25%25%P
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU   5 Specialty Tier 25%25%None
VIDEX 2GM PEDIATRIC TUBEX   3 Preferred Brand 25%25%None
VIDEX EC 125MG CAPSULE SA   4 Non-Preferred Brand 50%50%None
VIDEX EC 200MG CAPSULE SA   4 Non-Preferred Brand 50%50%None
VIDEX EC 250MG CAPSULE SA   4 Non-Preferred Brand 50%50%None
VIDEX EC 400MG CAPSULE SA   4 Non-Preferred Brand 50%50%None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]   5 Specialty Tier 25%25%None
VIGABATRIN 500 MG ORAL TABLET [SABRIL]   5 Specialty Tier 25%25%None
VIGAMOX 0.5% EYE DROPS   4 Non-Preferred Brand 50%50%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 50%50%P
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 50%50%P
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 50%50%P
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 50%50%P
VIMOVO 375-20 MG TABLET   4 Non-Preferred Brand 50%50%None
VIMOVO 500-20 MG TABLET   4 Non-Preferred Brand 50%50%None
VIMPAT 10 MG/ML SOLUTION   4 Non-Preferred Brand 50%50%None
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 50%50%None
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS   4 Non-Preferred Brand 50%50%None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 50%50%None
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 50%50%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 50%50%None
VINBLASTINE 1 MG/ML VIAL   2 Non-Preferred Generic $11.00$27.50None
VINCRISTINE 1MG/ML VIAL   2 Non-Preferred Generic $11.00$27.50None
VINCRISTINE 1MG/ML VIAL   2 Non-Preferred Generic $11.00$27.50None
VINORELBINE 10MG/ML VIAL 5ML VIAL   2 Non-Preferred Generic $11.00$27.50None
VIRACEPT 250MG TABLET   5 Specialty Tier 25%25%None
VIRACEPT 625MG TABLET   5 Specialty Tier 25%25%None
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 50%50%None
VIRAMUNE 50MG/5ML SUSP   4 Non-Preferred Brand 50%50%None
VIRAMUNE XR 100 MG TABLET   4 Non-Preferred Brand 50%50%None
VIRAZOLE 6 GM VIAL   4 Non-Preferred Brand 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIREAD 150 MG TABLET   3 Preferred Brand 25%25%None
VIREAD 200 MG TABLET   3 Preferred Brand 25%25%None
VIREAD 250 MG TABLET   3 Preferred Brand 25%25%None
VIREAD 300MG TABLET   3 Preferred Brand 25%25%None
VIREAD POWDER   3 Preferred Brand 25%25%None
VIROPTIC 1% EYE DROPS   4 Non-Preferred Brand 50%50%None
VISTIDE 75MG/ML VIAL   4 Non-Preferred Brand 50%50%None
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL   4 Non-Preferred Brand 50%50%None
VOLTAREN 1% GEL   4 Non-Preferred Brand 50%50%None
VORICONAZOLE 200 MG VIAL   2 Non-Preferred Generic $11.00$27.50None
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Non-Preferred Generic $11.00$27.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Voriconazole 40 mg/ml susp   2 Non-Preferred Generic $11.00$27.50None
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Non-Preferred Generic $11.00$27.50None
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%25%P
VPRIV INJECTION SOLUTION 2.5 MG/ML   5 Specialty Tier 25%25%None
Vyfemla 28 tablet   2 Non-Preferred Generic $11.00$27.50None
VYVANSE 30MG CAPSULE   4 Non-Preferred Brand 50%50%None
VYVANSE 40MG CAPSULE 100 EA   4 Non-Preferred Brand 50%50%None
VYVANSE 50MG CAPSULE   4 Non-Preferred Brand 50%50%None
VYVANSE 70MG CAPSULE   4 Non-Preferred Brand 50%50%None
VYVANSE CAPSULES 20MG 100 BOT   4 Non-Preferred Brand 50%50%None
VYVANSE CAPSULES 60MG 100 BOT   4 Non-Preferred Brand 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Blue Rx Plus (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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.