2017 Medicare Part D Plan Formulary Information |
Aetna Medicare OH Connect Gold (Regional PPO) (R6694-003-0)
Benefit Details
|
The Aetna Medicare OH Connect Gold (Regional PPO) (R6694-003-0) Formulary Drugs Starting with the Letter V in Statewide County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $34.50 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 |
Preferred Brand |
$47.00 | $141.00 | None |
VALACYCLOVIR 1000 MG ORAL TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
VALACYCLOVIR 500 MG ORAL TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
33% | N/A | P |
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 |
VALGANCICLOVIR HCL 50 MG/ML [Valcyte] |
5 |
Specialty Tier |
33% | N/A | None |
VALPROATE SODIUM 500 mg/5 ml vl |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE |
2 |
Generic |
$5.00 | $15.00 | None |
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 160 MG TABLET [Diovan] |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
VALSARTAN 320 MG TABLET [Diovan] |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
VALSARTAN 40 MG TABLET [Diovan] |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
VALSARTAN 80 MG TABLET [Diovan] |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
VANCOMYCIN HCL 125 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days |
VANCOMYCIN HCL 250 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
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 ) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VASCEPA 0.5 GM CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VASCEPA 1 GM CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | N/A | P |
VELCADE 3.5MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
2 |
Generic |
$5.00 | $15.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VENCLEXTA 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days |
VENCLEXTA 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
VENCLEXTA 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days |
VENCLEXTA STARTING PACK |
5 |
Specialty Tier |
33% | N/A | P Q:84 /365Days |
VENLAFAXINE HCL 100MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VENLAFAXINE HCL 25MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VENLAFAXINE HCL 37.5MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VENLAFAXINE HCL 50MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VENLAFAXINE HCL 75MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /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 |
$47.00 | $141.00 | Q:36 /30Days |
VERAPAMIL 120MG CAP PELLET |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL 180MG CAP PELLET |
2 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 2.5MG/ML AMPUL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VERAPAMIL 240MG CAP PELLET |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL 40MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 120 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 180 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL HCL 120MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
2 |
Generic |
$5.00 | $15.00 | None |
VERAPAMIL HCL 80MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$5.00 | $15.00 | None |
VEREGEN 15% OINTMENT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VERSACLOZ 50 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | S |
VESICARE 10MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VESICARE 5MG TABLET (90 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
Vestura 3 mg-0.02 mg tablet |
2 |
Generic |
$5.00 | $15.00 | None |
VIBERZI 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
VIBERZI 75 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
VICODIN 5-300 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
VICODIN ES 7.5-300 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
VICODIN HP 10-300 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days |
VIDEX 2GM PEDIATRIC TUBEX |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIENVA-28 TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /365Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | 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 Drug |
$100.00 | $300.00 | Q:60 /30Days |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days |
VINBLASTINE 1 MG/ML VIAL |
2 |
Generic |
$5.00 | $15.00 | P |
VINCRISTINE 1MG/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
VINCRISTINE 1MG/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
VINORELBINE 10MG/ML VIAL 5ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | 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 50MG/5ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIRAMUNE XR 100 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIREAD 150 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIREAD 200 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIREAD 250 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIREAD 300MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIREAD POWDER |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VOLTAREN 1% GEL |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:1000 /30Days |
VORICONAZOLE 200 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Voriconazole 40 mg/ml susp |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | 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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VOTRIENT 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
33% | N/A | P |
VRAYLAR 1.5 MG CAP |
5 |
Specialty Tier |
33% | N/A | S Q:30 /30Days |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:14 /365Days |
VRAYLAR 3 MG CAP |
5 |
Specialty Tier |
33% | N/A | S Q:30 /30Days |
VRAYLAR 4.5 MG CAP |
5 |
Specialty Tier |
33% | N/A | S Q:30 /30Days |
VRAYLAR 6 MG CAP |
5 |
Specialty Tier |
33% | N/A | S Q:30 /30Days |
Vyfemla 28 tablet |
2 |
Generic |
$5.00 | $15.00 | None |
VYTORIN 10/10MG TABLET (1000 CT) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
VYTORIN 10/20MG TABLET (1000 CT) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | 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 Drug |
$100.00 | $300.00 | S Q:30 /30Days |
VYTORIN 10/80MG TABLET 2500 BOT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |