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2016 Medicare Part D Plan Formulary Information
Martin's Point Generations Advantage Select (PPO) (H1365-001-0) Benefit Details
The Martin's Point Generations Advantage Select (PPO) (H1365-001-0) Formulary Drugs Starting with the Letter V in Androscoggin County, ME: CMS MA Region 1 which includes: ME Plan Monthly Premium: $79.00 Deductible: $0
Drugs Starting with Letter V Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter V Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VAGIFEM 10 MCG VAGINAL TAB	4	Non-Preferred Brand	$95.00	$250.00	None
VALACYCLOVIR 1000 MG ORAL TABLET	2	Generic	$8.00	$37.50	None
VALACYCLOVIR 500 MG ORAL TABLET	2	Generic	$8.00	$37.50	None
VALCHLOR 0.016% GEL	5	Specialty Tier	33%	33%	P
VALCYTE FOR ORAL SOLUTION 50MG/ML	5	Specialty Tier	33%	33%	None
VALGANCICLOVIR 450 MG TABLET [Valcyte]	5	Specialty Tier	33%	33%	None
VALPROATE SODIUM 500 mg/5 ml vl	2	Generic	$8.00	$37.50	None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE	2	Generic	$8.00	$37.50	None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE	2	Generic	$8.00	$37.50	None
VALSARTAN 160 MG TABLET [Diovan]	1	Preferred Generic	$0.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VALSARTAN 320 MG TABLET [Diovan]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN 40 MG TABLET [Diovan]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN 80 MG TABLET [Diovan]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]	1	Preferred Generic	$0.00	$10.00	None
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]	1	Preferred Generic	$0.00	$10.00	None
VANCOMYCIN HCL 125 MG CAPSULE	5	Specialty Tier	33%	33%	None
VANCOMYCIN HCL 250 MG CAPSULE	5	Specialty Tier	33%	33%	None
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )	2	Generic	$8.00	$37.50	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	$8.00	$37.50	None
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE)	2	Generic	$8.00	$37.50	None
VANDAZOLE 0.75% GEL WITH APPLICATOR	2	Generic	$8.00	$37.50	None
VAQTA 25 UNITS/0.5 ML SYRINGE	3	Preferred Brand	$40.00	$117.50	None
VAQTA 50 UNITS/ML SYRINGE	3	Preferred Brand	$40.00	$117.50	None
VARIVAX VACCINE W/DILUENT	3	Preferred Brand	$40.00	$117.50	None
VASCEPA 1 GM CAPSULE	4	Non-Preferred Brand	$95.00	$250.00	None
VELCADE 3.5MG VIAL	5	Specialty Tier	33%	33%	P
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	2	Generic	$8.00	$37.50	None
VENCLEXTA 10 MG TABLET	4	Non-Preferred Brand	$95.00	$250.00	P
VENCLEXTA 100 MG TABLET	5	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VENCLEXTA 50 MG TABLET	4	Non-Preferred Brand	$95.00	$250.00	P
VENCLEXTA STARTING PACK	5	Specialty Tier	33%	33%	P
VENLAFAXINE HCL 100MG TABLET	2	Generic	$8.00	$37.50	None
VENLAFAXINE HCL 25MG TABLET	2	Generic	$8.00	$37.50	None
VENLAFAXINE HCL 37.5MG TABLET	2	Generic	$8.00	$37.50	None
VENLAFAXINE HCL 50MG TABLET	2	Generic	$8.00	$37.50	None
VENLAFAXINE HCL 75MG TABLET	2	Generic	$8.00	$37.50	None
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE	2	Generic	$8.00	$37.50	Q:60 /30Days
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE	2	Generic	$8.00	$37.50	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE	2	Generic	$8.00	$37.50	Q:30 /30Days
VENTOLIN HFA 90MCG INHALER	3	Preferred Brand	$40.00	$117.50	Q:36 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERAPAMIL 120MG CAP PELLET	2	Generic	$8.00	$37.50	None
VERAPAMIL 180MG CAP PELLET	2	Generic	$8.00	$37.50	None
VERAPAMIL 2.5MG/ML AMPUL	2	Generic	$8.00	$37.50	None
VERAPAMIL 240MG CAP PELLET	2	Generic	$8.00	$37.50	None
VERAPAMIL 40MG TABLET	1	Preferred Generic	$0.00	$10.00	None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS	2	Generic	$8.00	$37.50	None
VERAPAMIL ER 120 MG TABLET	1	Preferred Generic	$0.00	$10.00	None
VERAPAMIL ER 120 MG TABLET	1	Preferred Generic	$0.00	$10.00	None
VERAPAMIL ER 180 MG TABLET	1	Preferred Generic	$0.00	$10.00	None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)	2	Generic	$8.00	$37.50	None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS	2	Generic	$8.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERAPAMIL HCL 120MG TABLET	1	Preferred Generic	$0.00	$10.00	None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE	2	Generic	$8.00	$37.50	None
VERAPAMIL HCL 80MG TABLET	1	Preferred Generic	$0.00	$10.00	None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	1	Preferred Generic	$0.00	$10.00	None
VERSACLOZ 50 MG/ML SUSPENSION	5	Specialty Tier	33%	33%	P Q:600 /30Days
VESICARE 10MG TABLET	4	Non-Preferred Brand	$95.00	$250.00	Q:30 /30Days
VESICARE 5MG TABLET (90 CT)	4	Non-Preferred Brand	$95.00	$250.00	Q:30 /30Days
Vestura 3 mg-0.02 mg tablet	2	Generic	$8.00	$37.50	None
VICTOZA 3-PAK 18 MG/3 ML PEN	3	Preferred Brand	$40.00	$117.50	Q:9 /30Days
VIDEX 2GM PEDIATRIC TUBEX	4	Non-Preferred Brand	$95.00	$250.00	None
VIENVA-28 TABLET	2	Generic	$8.00	$37.50	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]	5	Specialty Tier	33%	33%	P Q:180 /30Days
VIGABATRIN 500 MG ORAL TABLET [SABRIL]	5	Specialty Tier	33%	33%	P Q:180 /30Days
VIGAMOX 0.5% EYE DROPS	3	Preferred Brand	$40.00	$117.50	None
VIIBRYD 10-20 MG STARTER PACK	4	Non-Preferred Brand	$95.00	$250.00	None
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	$95.00	$250.00	Q:30 /30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	$95.00	$250.00	Q:30 /30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	$95.00	$250.00	Q:30 /30Days
VIMPAT 10 MG/ML SOLUTION	4	Non-Preferred Brand	$95.00	$250.00	Q:1200 /30Days
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	33%	33%	Q:60 /30Days
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS	4	Non-Preferred Brand	$95.00	$250.00	None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	33%	33%	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	5	Specialty Tier	33%	33%	Q:60 /30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	4	Non-Preferred Brand	$95.00	$250.00	Q:180 /30Days
VINBLASTINE 1 MG/ML VIAL	3	Preferred Brand	$40.00	$117.50	P
VINCRISTINE 1MG/ML VIAL	2	Generic	$8.00	$37.50	P
VINCRISTINE 1MG/ML VIAL	2	Generic	$8.00	$37.50	P
VINORELBINE 10MG/ML VIAL 5ML VIAL	2	Generic	$8.00	$37.50	P
VIRACEPT 250MG TABLET	5	Specialty Tier	33%	33%	None
VIRACEPT 625MG TABLET	5	Specialty Tier	33%	33%	None
VIRAMUNE XR 100 MG TABLET	4	Non-Preferred Brand	$95.00	$250.00	None
VIREAD 150 MG TABLET	5	Specialty Tier	33%	33%	None
VIREAD 200 MG TABLET	5	Specialty Tier	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIREAD 250 MG TABLET	5	Specialty Tier	33%	33%	None
VIREAD 300MG TABLET	5	Specialty Tier	33%	33%	None
VIREAD POWDER	5	Specialty Tier	33%	33%	None
VITEKTA 150 MG TABLET	5	Specialty Tier	33%	33%	None
VITEKTA 85 MG TABLET	5	Specialty Tier	33%	33%	None
VOLTAREN 1% GEL	3	Preferred Brand	$40.00	$117.50	None
VORICONAZOLE 200 MG VIAL	2	Generic	$8.00	$37.50	None
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	33%	33%	None
Voriconazole 40 mg/ml susp	5	Specialty Tier	33%	33%	None
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	33%	33%	None
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE	5	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VRAYLAR 1.5 MG CAP	5	Specialty Tier	33%	33%	S Q:120 /30Days
VRAYLAR 1.5 MG-3 MG PACK	4	Non-Preferred Brand	$95.00	$250.00	S
VRAYLAR 3 MG CAP	5	Specialty Tier	33%	33%	S Q:60 /30Days
VRAYLAR 4.5 MG CAP	5	Specialty Tier	33%	33%	S Q:30 /30Days
VRAYLAR 6 MG CAP	5	Specialty Tier	33%	33%	S Q:30 /30Days
Vyfemla 28 tablet	2	Generic	$8.00	$37.50	None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Martin's Point Generations Advantage Select (PPO) 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 $360 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 $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2016 )

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.