2018 Medicare Part D Plan Formulary Information |
Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0)
Benefit Details
|
The Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0) Formulary Drugs Starting with the Letter V in Lea County, NM: CMS MA Region 20 which includes: NM Plan Monthly Premium: $163.00 Deductible: $375 |
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 |
VALACYCLOVIR HCL 1 GRAM TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
VALACYCLOVIR HCL 500 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
25% | N/A | P |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
5 |
Specialty Tier |
25% | N/A | None |
VALGANCICLOVIR HCL 50 MG/ML [Valcyte] |
5 |
Specialty Tier |
25% | N/A | None |
VALPROATE SOD 500 MG/5 ML VIAL [Depacon] |
2 |
Generic |
$10.00 | $20.00 | None |
VALPROIC ACID 250 MG CAPSULE [Depakene] |
2 |
Generic |
$10.00 | $20.00 | None |
VALPROIC ACID 500 MG/10 ML Solution [Depakene] |
2 |
Generic |
$10.00 | $20.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
VALSARTAN 320 MG TABLET [Diovan] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 40 MG TABLET [Diovan] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
VALSARTAN 80 MG TABLET [Diovan] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT] |
2 |
Generic |
$10.00 | $20.00 | S |
VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT] |
2 |
Generic |
$10.00 | $20.00 | S |
VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT] |
2 |
Generic |
$10.00 | $20.00 | S |
VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT] |
2 |
Generic |
$10.00 | $20.00 | S |
VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT] |
2 |
Generic |
$10.00 | $20.00 | S |
VANCOMYCIN 500 MG VIAL |
2 |
Generic |
$10.00 | $20.00 | None |
VANCOMYCIN HCL 125 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
VANCOMYCIN HCL 250 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VAQTA 50 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Vaqta Hepatitis A Vaccine Adult 50 Unit / mL Injection Single Dose Vial 1 mL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Varicella-Zoster Immune Globulin 1.2 ML 104 UNT/ML Injection [Varizig] |
5 |
Specialty Tier |
25% | N/A | P |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VASCEPA 1 GM CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:4 /1Days |
VELCADE 3.5MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
VELIVET 28 DAY TABLET [Velivet] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VENCLEXTA 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:2 /1Days |
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% | N/A | P Q:4 /1Days |
VENCLEXTA 50 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:1 /1Days |
VENCLEXTA STARTING PACK |
5 |
Specialty Tier |
25% | N/A | P Q:84 /365Days |
VENLAFAXINE HCL 100 MG TABLET [Effexor] |
2 |
Generic |
$10.00 | $20.00 | None |
VENLAFAXINE HCL 25 MG TABLET [Effexor] |
2 |
Generic |
$10.00 | $20.00 | None |
VENLAFAXINE HCL 37.5 MG TABLET [Effexor] |
2 |
Generic |
$10.00 | $20.00 | None |
VENLAFAXINE HCL 50 MG TABLET [Effexor] |
2 |
Generic |
$10.00 | $20.00 | None |
VENLAFAXINE HCL 75 MG TABLET [Effexor] |
2 |
Generic |
$10.00 | $20.00 | None |
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR] |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
VENLAFAXINE HCL ER 150 MG TABLET 24 [Venlafaxine] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:2 /1Days |
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR] |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL ER 37.5 MG TAB ER 24 [Venlafaxine] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:2 /1Days |
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR] |
2 |
Generic |
$10.00 | $20.00 | Q:3 /1Days |
VENLAFAXINE HCL ER 75 MG TABLET 24 [Venlafaxine] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:3 /1Days |
Ventavis 0.01mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:3 /1Days |
Ventavis 0.02mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:3 /1Days |
VENTOLIN HFA 90MCG INHALER |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VERAPAMIL 120 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL 120MG CAP PELLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL 180MG CAP PELLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL 240MG CAP PELLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL 40MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 80 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL ER 120 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL ER 180 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL ER 240 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
2 |
Generic |
$10.00 | $20.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
2 |
Generic |
$10.00 | $20.00 | None |
VERSACLOZ 50 MG/ML SUSPENSION |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
VERZENIO 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
VERZENIO 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERZENIO 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
VERZENIO 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
VESICARE 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
VESICARE 5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
VESTURA 3 MG-0.02 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:9 /30Days |
VIDEX 4 GM PEDIATRIC SOLN |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VIDEX EC 125MG CAPSULE SA |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VIEKIRA PAK |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
VIEKIRA XR TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:3 /1Days |
VIENVA-28 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
25% | N/A | None |
VIGABATRIN 500 MG POWDER PACKET [SABRIL] |
5 |
Specialty Tier |
25% | N/A | None |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:2 /1Days |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:2 /1Days |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:2 /1Days |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
VIREAD POWDER |
5 |
Specialty Tier |
25% | N/A | None |
VORICONAZOLE 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
VORICONAZOLE 200 MG VIAL |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
Voriconazole 40 MG/ML Oral Suspension |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VOTRIENT 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
25% | N/A | None |
VRAYLAR 1.5 MG CAP |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:14 /365Days |
VRAYLAR 3 MG CAP |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
VRAYLAR 4.5 MG CAP |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
VRAYLAR 6 MG CAP |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
Vyfemla 28 tablet |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VYLIBRA 28 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
VYVANSE 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
VYVANSE 30MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYVANSE 40MG CAPSULE 100 EA |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
VYVANSE 50MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
VYVANSE 70MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
VYVANSE CAPSULES 20MG 100 BOT |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
VYVANSE CAPSULES 60MG 100 BOT |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /1Days |
VYXEOS 44 MG-100 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |