2015 Medicare Part D Plan Formulary Information |
Symphonix Premier Rx (PDP) (S0522-072-0)
Benefit Details
|
The Symphonix Premier Rx (PDP) (S0522-072-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $84.20 Deductible: $0 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 |
VALACYCLOVIR 1000 MG ORAL TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
33% | N/A | P |
VALCYTE 450MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VALCYTE FOR ORAL SOLUTION 50MG/ML |
5 |
Specialty Tier |
33% | N/A | None |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
5 |
Specialty Tier |
33% | N/A | None |
VALPROATE SODIUM 500 mg/5 ml vl |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 320 MG TABLET [Diovan] |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:60 /30Days |
VALSARTAN 80 MG TABLET [Diovan] |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
VANATOL LQ ORAL SOLUTION |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | P Q:2700 /30Days |
VANCOMYCIN HCL 125 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
VANCOMYCIN HCL 250 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VANCOMYCIN HYDROCHLORIDE 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE) |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
VAQTA 25 UNITS/0.5ML SYRINGE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VAQTA 25 UNITS/0.5ML VIAL |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VARIZIG 125 UNIT/1.2 ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
VASCEPA 1 GM CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:120 /30Days |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VELTIN 10; 0.25mg/g; mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | P |
VENLAFAXINE HCL 100MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HCL 25MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HCL 37.5MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HCL 50MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:210 /30Days |
VENLAFAXINE HCL 75MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HCL ER TAB 225 MG |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:90 /30Days |
Ventavis 0.01mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
Ventavis 0.02mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
VENTOLIN HFA 90MCG INHALER |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:54 /30Days |
VERAPAMIL 120MG CAP PELLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL 180MG CAP PELLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL 2.5MG/ML AMPUL |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 240MG CAP PELLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL 40MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL ER 120 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
VERAPAMIL ER 180 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL HCL 120MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VERAPAMIL HCL 80MG TABLET |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERSACLOZ 50 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | None |
VESICARE 10MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days |
VESICARE 5MG TABLET (90 CT) |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days |
Vestura 3 mg-0.02 mg tablet |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VEXOL 1% EYE DROPS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VFEND 40MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | None |
VIBRAMYCIN 50MG/5ML SYRUP |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VICODIN 5-300 MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:390 /30Days |
VICODIN ES 7.5-300 MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:390 /30Days |
VICODIN HP 10-300 MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:390 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$30.00 | $90.00 | S Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
5 |
Specialty Tier |
33% | N/A | P |
VIDEX 2GM PEDIATRIC TUBEX |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VIEKIRA PAK |
5 |
Specialty Tier |
33% | N/A | P Q:112 /28Days |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
5 |
Specialty Tier |
33% | N/A | P |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
33% | N/A | P |
VIGAMOX 0.5% EYE DROPS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VIIBRYD 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VINBLASTINE 1 MG/ML VIAL |
3 |
Preferred Brand |
$30.00 | $90.00 | P |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | P |
VINCRISTINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | P |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None |
VIRAMUNE XR 100 MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VIRAZOLE 6 GM VIAL |
5 |
Specialty Tier |
33% | N/A | None |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIREAD 300MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VIREAD POWDER |
5 |
Specialty Tier |
33% | N/A | None |
VITEKTA 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
VITEKTA 85 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
VOLTAREN 1% GEL |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
VORICONAZOLE 200 MG VIAL |
5 |
Specialty Tier |
33% | N/A | 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 | P Q:120 /30Days |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
33% | N/A | P |
Vyfemla 28 tablet |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
VYTORIN 10/10MG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | S Q:30 /30Days |
VYTORIN 10/20MG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | S 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) |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | S Q:30 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | P Q:30 /30Days |