2016 Medicare Part D Plan Formulary Information |
Blue Advantage Complete (PPO) (H0104-014-0)
Benefit Details
|
The Blue Advantage Complete (PPO) (H0104-014-0) Formulary Drugs Starting with the Letter V in Shelby County, AL: CMS MA Region 10 which includes: AL Plan Monthly Premium: $0.00 Deductible: $360 |
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 |
$47.00 | $94.00 | None |
VALACYCLOVIR 1000 MG ORAL TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
25% | 25% | None |
VALCYTE FOR ORAL SOLUTION 50MG/ML |
5 |
Specialty Tier |
25% | 25% | None |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
5 |
Specialty Tier |
25% | 25% | None |
VALPROATE SODIUM 500 mg/5 ml vl |
2* |
Generic |
$20.00 | $40.00 | None |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
2* |
Generic |
$20.00 | $40.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
2* |
Generic |
$20.00 | $40.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
6* |
Select Care Drugs |
$2.00 | $4.00 | 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] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:60 /30Days |
VALSARTAN 80 MG TABLET [Diovan] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
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* |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA |
2* |
Generic |
$20.00 | $40.00 | None |
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE) |
2* |
Generic |
$20.00 | $40.00 | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2* |
Generic |
$20.00 | $40.00 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
VARIVAX VACCINE W/DILUENT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
VASCEPA 1 GM CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | 25% | 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* |
Generic |
$20.00 | $40.00 | None |
VENCLEXTA 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENCLEXTA 100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
VENCLEXTA 50 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P Q:30 /30Days |
VENCLEXTA STARTING PACK |
5 |
Specialty Tier |
25% | 25% | P Q:42 /28Days |
VENLAFAXINE HCL 100MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
VENLAFAXINE HCL 25MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
VENLAFAXINE HCL 37.5MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
VENLAFAXINE HCL 50MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
VENLAFAXINE HCL 75MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE |
2* |
Generic |
$20.00 | $40.00 | Q:90 /30Days |
Ventavis 0.01mg/mL |
5 |
Specialty Tier |
25% | 25% | P Q:270 /30Days |
Ventavis 0.02mg/mL |
5 |
Specialty Tier |
25% | 25% | P Q:270 /30Days |
VENTOLIN HFA 90MCG INHALER |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:36 /30Days |
VERAPAMIL 120MG CAP PELLET |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL 180MG CAP PELLET |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL 240MG CAP PELLET |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL 40MG TABLET |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
2* |
Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL ER 120 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL ER 120 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL ER 180 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL HCL 120MG TABLET |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
2* |
Generic |
$20.00 | $40.00 | None |
VERAPAMIL HCL 80MG TABLET |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2* |
Generic |
$20.00 | $40.00 | None |
VERSACLOZ 50 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | 25% | P Q:540 /30Days |
VESICARE 10MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VESICARE 5MG TABLET (90 CT) |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days |
Vestura 3 mg-0.02 mg tablet |
2* |
Generic |
$20.00 | $40.00 | None |
VICODIN 5-300 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:360 /30Days |
VICODIN ES 7.5-300 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:180 /30Days |
VICODIN HP 10-300 MG TABLET |
2* |
Generic |
$20.00 | $40.00 | Q:180 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days |
VIDEX 2GM PEDIATRIC TUBEX |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:1200 /30Days |
VIEKIRA PAK |
5 |
Specialty Tier |
25% | 25% | P |
VIENVA-28 TABLET |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIGAMOX 0.5% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VINBLASTINE 1 MG/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
VINCRISTINE 1MG/ML VIAL |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
VINCRISTINE 1MG/ML VIAL |
1* |
Preferred Generic |
$4.00 | $8.00 | None |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
2* |
Generic |
$20.00 | $40.00 | None |
VIOKACE 10,440-39,150 UNITS TB |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
VIOKACE 20,880-78,300 UNITS TB |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:270 /30Days |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:120 /30Days |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:1200 /30Days |
VIRAMUNE XR 100 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:120 /30Days |
VIRAZOLE 6 GM VIAL |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
VIREAD 300MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
VIREAD POWDER |
5 |
Specialty Tier |
25% | 25% | Q:240 /30Days |
VITEKTA 150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
VITEKTA 85 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
5 |
Specialty Tier |
25% | 25% | None |
VOLTAREN 1% GEL |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | S |
VORICONAZOLE 200 MG VIAL |
2* |
Generic |
$20.00 | $40.00 | P |
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Voriconazole 40 mg/ml susp |
5 |
Specialty Tier |
25% | 25% | P |
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | 25% | P |
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
25% | 25% | None |
VRAYLAR 1.5 MG CAP |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P Q:28 /28Days |
VRAYLAR 3 MG CAP |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
VRAYLAR 4.5 MG CAP |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
VRAYLAR 6 MG CAP |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
Vyfemla 28 tablet |
2* |
Generic |
$20.00 | $40.00 | None |
VYTORIN 10/10MG TABLET (1000 CT) |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYTORIN 10/20MG TABLET (1000 CT) |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days |
VYTORIN 10/40MG TABLET (500 CT) |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days |