2015 Medicare Part D Plan Formulary Information |
Olympus - Constellation Health (PPO) (H4876-001-0)
Benefit Details
|
The Olympus - Constellation Health (PPO) (H4876-001-0) Formulary Drugs Starting with the Letter V in VIEQUES County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $51.00 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 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
VALACYCLOVIR 1000 MG ORAL TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VALCHLOR 0.016% GEL |
4 |
Specialty Tier |
33% | 33% | None |
VALCYTE 450MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
4 |
Specialty Tier |
33% | 33% | None |
Valium 10mg/1 500 TABLET BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:120 /30Days |
Valium 2mg/1 100 TABLET BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:120 /30Days |
Valium 5mg/1 500 TABLET BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:120 /30Days |
VALPROATE SODIUM 500 mg/5 ml vl |
1 |
Generic |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
VALSARTAN 320 MG TABLET [Diovan] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
VALSARTAN 80 MG TABLET [Diovan] |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALTREX 1GM CAPLET (90 CT) |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VALTREX 500MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VANCOCIN HCL 125 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
VANCOCIN HCL 250 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
VANCOMYCIN HCL 125 MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
VANCOMYCIN HCL 250 MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
1 |
Generic |
$5.00 | $15.00 | P |
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE) |
1 |
Generic |
$5.00 | $15.00 | P |
VAQTA 25 UNITS/0.5ML VIAL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VARIVAX VACCINE W/DILUENT |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VASERETIC 10-25 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VASOTEC 10 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VASOTEC 2.5 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VASOTEC 20 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VASOTEC 5 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VELCADE 3.5MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
4 |
Specialty Tier |
33% | 33% | None |
VENLAFAXINE HCL 100MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VENLAFAXINE HCL 25MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL 37.5MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VENLAFAXINE HCL 50MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VENLAFAXINE HCL 75MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE |
1 |
Generic |
$5.00 | $15.00 | Q:90 /30Days |
Ventavis 0.01mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
Ventavis 0.02mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
VERAPAMIL 120MG CAP PELLET |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL 180MG CAP PELLET |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL 240MG CAP PELLET |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 40MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 120 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 180 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL HCL 120MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
1 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL HCL 80MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | None |
VERELAN 120 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERELAN 180 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VERELAN 240 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VERELAN 360 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VERELAN PM 100 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VERELAN PM 200 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VERELAN PM 300 MG CAP PELLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VERSACLOZ 50 MG/ML SUSPENSION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Vestura 3 mg-0.02 mg tablet |
1 |
Generic |
$5.00 | $15.00 | None |
VFEND 200MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VFEND 40MG/ML SUSPENSION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VFEND 50MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VFEND IV 200MG VIAL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
VIBRAMYCIN 100MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VICOPROFEN 200/7.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:150 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:9 /30Days |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
4 |
Specialty Tier |
33% | 33% | P |
VIDEX 2GM PEDIATRIC TUBEX |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIDEX EC 125MG CAPSULE SA |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIDEX EC 200MG CAPSULE SA |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIDEX EC 250MG CAPSULE SA |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIDEX EC 400MG CAPSULE SA |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIGAMOX 0.5% EYE DROPS |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | 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 |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIOKACE 20,880-78,300 UNITS TB |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIRACEPT 250MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIRACEPT 625MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIRAMUNE 200MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIRAMUNE 50MG/5ML SUSP |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIRAMUNE XR 100 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VIREAD 150 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD 200 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD 250 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIREAD 300MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD POWDER |
4 |
Specialty Tier |
33% | 33% | None |
VIROPTIC 1% EYE DROPS |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VITEKTA 150 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VITEKTA 85 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VOLTAREN 1% GEL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VOLTAREN-XR 100MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
VORICONAZOLE 200 MG VIAL |
1 |
Generic |
$5.00 | $15.00 | P |
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | None |
Voriconazole 40 mg/ml susp |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | None |
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE |
4 |
Specialty Tier |
33% | 33% | P |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
4 |
Specialty Tier |
33% | 33% | P |
Vyfemla 28 tablet |
1 |
Generic |
$5.00 | $15.00 | None |
VYTORIN 10/10MG TABLET (1000 CT) |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
VYTORIN 10/20MG TABLET (1000 CT) |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
VYTORIN 10/40MG TABLET (500 CT) |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
2 |
Preferred Brand |
$25.00 | $75.00 | P Q:30 /30Days |