2016 Medicare Part D Plan Formulary Information |
Freedom Platinum Plan Rx (HMO) (H5427-089-0)
Benefit Details
|
The Freedom Platinum Plan Rx (HMO) (H5427-089-0) Formulary Drugs Starting with the Letter V in Osceola County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 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 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VALACYCLOVIR 1000 MG ORAL TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
VALCHLOR 0.016% GEL |
4 |
Specialty Tier |
33% | 33% | None |
VALCYTE 450MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VALCYTE FOR ORAL SOLUTION 50MG/ML |
4 |
Specialty Tier |
33% | 33% | None |
VALPROATE SODIUM 500 mg/5 ml vl |
1 |
Generic |
$0.00 | $0.00 | None |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
1 |
Generic |
$0.00 | $0.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic |
$0.00 | $0.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 320 MG TABLET [Diovan] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN 80 MG TABLET [Diovan] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
VANCOMYCIN HCL 125 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
VANCOMYCIN HCL 250 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
2 |
Preferred Brand |
$35.00 | $70.00 | P |
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 |
Preferred Brand |
$35.00 | $70.00 | P |
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE) |
2 |
Preferred Brand |
$35.00 | $70.00 | P |
VAQTA 25 UNITS/0.5 ML SYRINGE |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
VARIVAX VACCINE W/DILUENT |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
VARIZIG 125 UNIT/1.2 ML VIAL |
4 |
Specialty Tier |
33% | 33% | None |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
4 |
Specialty Tier |
33% | 33% | P |
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 |
$0.00 | $0.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VENCLEXTA 10 MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENCLEXTA 100 MG TABLET |
4 |
Specialty Tier |
33% | 33% | Q:120 /30Days |
VENCLEXTA 50 MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VENCLEXTA STARTING PACK |
4 |
Specialty Tier |
33% | 33% | Q:42 /28Days |
VENLAFAXINE HCL 100MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VENLAFAXINE HCL 25MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VENLAFAXINE HCL 37.5MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VENLAFAXINE HCL 50MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VENLAFAXINE HCL 75MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VENLAFAXINE HCL ER TAB 225 MG |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
Ventavis 0.01mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
Ventavis 0.02mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
VENTOLIN HFA 90MCG INHALER |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:48 /30Days |
VERAPAMIL 120MG CAP PELLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL 180MG CAP PELLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL 2.5MG/ML AMPUL |
1 |
Generic |
$0.00 | $0.00 | P |
VERAPAMIL 240MG CAP PELLET |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 40MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL ER 120 MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL ER 120 MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL ER 180 MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL HCL 120MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
1 |
Generic |
$0.00 | $0.00 | None |
VERAPAMIL HCL 80MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VEREGEN 15% OINTMENT |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VERSACLOZ 50 MG/ML SUSPENSION |
4 |
Specialty Tier |
33% | 33% | None |
VESICARE 10MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VESICARE 5MG TABLET (90 CT) |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VFEND 200MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VFEND 40MG/ML SUSPENSION |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VFEND 50MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VFEND IV 200MG VIAL |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:9 /30Days |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
VIDEX 2GM PEDIATRIC TUBEX |
2 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
4 |
Specialty Tier |
33% | 33% | P |
VIGAMOX 0.5% EYE DROPS |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VIIBRYD 10-20 MG STARTER PACK |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:60 /30Days |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:60 /30Days |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:60 /30Days |
VINBLASTINE 1 MG/ML VIAL |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
VINCRISTINE 1MG/ML VIAL |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
VIRACEPT 250MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIRACEPT 625MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIRAMUNE 200MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VIRAMUNE 50MG/5ML SUSP |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VIRAMUNE XR 100 MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIRAZOLE 6 GM VIAL |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD 150 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD 200 MG TABLET |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VIREAD 250 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD 300MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VIREAD POWDER |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
VITEKTA 150 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
VITEKTA 85 MG TABLET |
4 |
Specialty Tier |
33% | 33% | 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 |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:10 /30Days |
Vivelle Dot 0.0375mg/d 3 PACKET per CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:10 /30Days |
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 |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:10 /30Days |
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 |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:10 /30Days |
VIVELLE-DOT 0.075MG PATCH 1X3X8 POUCH CRTN |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:10 /30Days |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | 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 |
VRAYLAR 1.5 MG CAP |
4 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
VRAYLAR 1.5 MG-3 MG PACK |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:28 /28Days |
VRAYLAR 3 MG CAP |
4 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
VRAYLAR 4.5 MG CAP |
4 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
VRAYLAR 6 MG CAP |
4 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
VYTORIN 10/10MG TABLET (1000 CT) |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | 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 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VYTORIN 10/40MG TABLET (500 CT) |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |