2018 Medicare Part D Plan Formulary Information |
PriorityMedicare Merit (PPO) (H4875-016-5)
Benefit Details
|
The PriorityMedicare Merit (PPO) (H4875-016-5) Formulary Drugs Starting with the Letter V in Berrien County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $63.00 Deductible: $75 |
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 |
2* |
Generic |
$10.00 | N/A | None |
VALACYCLOVIR HCL 500 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VALCYTE 450MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
5 |
Specialty Tier |
31% | N/A | None |
VALPROATE SOD 500 MG/5 ML VIAL [Depacon] |
2* |
Generic |
$10.00 | N/A | None |
VALPROIC ACID 250 MG CAPSULE [Depakene] |
2* |
Generic |
$10.00 | N/A | None |
VALPROIC ACID 500 MG/10 ML Solution [Depakene] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN 160 MG TABLET [Diovan] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN 320 MG TABLET [Diovan] |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 40 MG TABLET [Diovan] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN 80 MG TABLET [Diovan] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT] |
2* |
Generic |
$10.00 | N/A | None |
VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT] |
2* |
Generic |
$10.00 | N/A | None |
VANCOMYCIN 500 MG VIAL |
2* |
Generic |
$10.00 | N/A | None |
VANCOMYCIN HCL 125 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
VANCOMYCIN HCL 250 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE ) |
2* |
Generic |
$10.00 | N/A | 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 |
$10.00 | N/A | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
3 |
Preferred Brand |
$42.00 | N/A | None |
VAQTA 50 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$42.00 | N/A | None |
Vaqta Hepatitis A Vaccine Adult 50 Unit / mL Injection Single Dose Vial 1 mL |
3 |
Preferred Brand |
$42.00 | N/A | None |
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL |
3 |
Preferred Brand |
$42.00 | N/A | None |
Varicella-Zoster Immune Globulin 1.2 ML 104 UNT/ML Injection [Varizig] |
3 |
Preferred Brand |
$42.00 | N/A | None |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$42.00 | N/A | None |
VASCEPA 0.5 GM CAPSULE |
4 |
Non-Preferred Drug |
45% | N/A | P |
VASCEPA 1 GM CAPSULE |
4 |
Non-Preferred Drug |
45% | N/A | P |
VECAMYL 2.5 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VECTIBIX 100 MG/5 ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VELCADE 3.5MG VIAL |
3 |
Preferred Brand |
$42.00 | N/A | P |
VELIVET 28 DAY TABLET [Velivet] |
2* |
Generic |
$10.00 | N/A | None |
VELPHORO 500 MG CHEWABLE TAB |
5 |
Specialty Tier |
31% | N/A | S |
VELTASSA 16.8 GM POWDER PACKET |
3 |
Preferred Brand |
$42.00 | N/A | Q:30 /30Days |
VELTASSA 25.2 GM POWDER PACKET |
3 |
Preferred Brand |
$42.00 | N/A | Q:30 /30Days |
VELTASSA 8.4 GM POWDER PACKET |
3 |
Preferred Brand |
$42.00 | N/A | Q:30 /30Days |
VEMLIDY 25 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VENCLEXTA 10 MG TABLET |
4 |
Non-Preferred Drug |
45% | N/A | P |
VENCLEXTA 100 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
VENCLEXTA 50 MG TABLET |
4 |
Non-Preferred Drug |
45% | N/A | P |
VENCLEXTA STARTING PACK |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL 100 MG TABLET [Effexor] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL 25 MG TABLET [Effexor] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL 37.5 MG TABLET [Effexor] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL 50 MG TABLET [Effexor] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL 75 MG TABLET [Effexor] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL ER 150 MG TABLET 24 [Venlafaxine] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR] |
1* |
Preferred Generic |
$2.00 | N/A | None |
VENLAFAXINE HCL ER 37.5 MG TAB ER 24 [Venlafaxine] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR] |
2* |
Generic |
$10.00 | N/A | None |
VENLAFAXINE HCL ER 75 MG TABLET 24 [Venlafaxine] |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ventavis 0.01mg/mL |
5 |
Specialty Tier |
31% | N/A | P |
Ventavis 0.02mg/mL |
5 |
Specialty Tier |
31% | N/A | P |
VENTOLIN HFA 90MCG INHALER |
4 |
Non-Preferred Drug |
45% | N/A | None |
VERAPAMIL 120 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
VERAPAMIL 120MG CAP PELLET |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL 180MG CAP PELLET |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL 240MG CAP PELLET |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL 40MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL 80 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL ER 120 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL ER 180 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL ER 240 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS |
2* |
Generic |
$10.00 | N/A | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
2* |
Generic |
$10.00 | N/A | None |
VEREGEN 15% OINTMENT |
4 |
Non-Preferred Drug |
45% | N/A | None |
VERSACLOZ 50 MG/ML SUSPENSION |
5 |
Specialty Tier |
31% | N/A | None |
VERZENIO 100 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
VERZENIO 150 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
VERZENIO 200 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
VERZENIO 50 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VESICARE 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
VESICARE 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
VICODIN 5-300 MG TABLET |
2* |
Generic |
$10.00 | N/A | Q:360 /30Days |
VICODIN ES 7.5-300 MG TABLET |
2* |
Generic |
$10.00 | N/A | Q:360 /30Days |
VICODIN HP 10-300 MG TABLET |
2* |
Generic |
$10.00 | N/A | Q:360 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
4 |
Non-Preferred Drug |
45% | N/A | S |
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU |
5 |
Specialty Tier |
31% | N/A | P |
VIDEX 4 GM PEDIATRIC SOLN |
3 |
Preferred Brand |
$42.00 | N/A | None |
VIDEX EC 125MG CAPSULE SA |
4 |
Non-Preferred Drug |
45% | N/A | None |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
5 |
Specialty Tier |
31% | N/A | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIGABATRIN 500 MG POWDER PACKET [SABRIL] |
5 |
Specialty Tier |
31% | N/A | None |
VIGAMOX 0.5% EYE DROPS |
3 |
Preferred Brand |
$42.00 | N/A | None |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | N/A | None |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
45% | N/A | None |
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Drug |
45% | N/A | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
45% | N/A | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
45% | N/A | None |
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 |
45% | N/A | None |
VINBLASTINE 1 MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | P |
VINCRISTINE 1MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | P |
VINCRISTINE 1MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | P |
VINORELBINE 50 MG/5 ML VIAL |
2* |
Generic |
$10.00 | N/A | P |
VIOKACE 10,440-39,150 UNITS TB |
4 |
Non-Preferred Drug |
45% | N/A | None |
VIOKACE 20,880-78,300 UNITS TB |
4 |
Non-Preferred Drug |
45% | N/A | None |
VIRACEPT 250MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
VIRACEPT 625MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
VIRAMUNE 200MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Drug |
45% | N/A | Q:1200 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VIREAD 300MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VIREAD POWDER |
5 |
Specialty Tier |
31% | N/A | None |
VORICONAZOLE 200 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VORICONAZOLE 200 MG VIAL |
4 |
Non-Preferred Drug |
45% | N/A | None |
Voriconazole 40 MG/ML Oral Suspension |
5 |
Specialty Tier |
31% | N/A | None |
VORICONAZOLE 50 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
VOTRIENT 200 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
VPRIV INJECTION SOLUTION 2.5 MG/ML |
5 |
Specialty Tier |
31% | N/A | None |
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 |
31% | N/A | S |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Drug |
45% | N/A | S |
VRAYLAR 3 MG CAP |
5 |
Specialty Tier |
31% | N/A | S |
VRAYLAR 4.5 MG CAP |
5 |
Specialty Tier |
31% | N/A | S |
VRAYLAR 6 MG CAP |
5 |
Specialty Tier |
31% | N/A | S |
VYVANSE 10 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 10 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 20 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 30 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 30MG CAPSULE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 40 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
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 |
45% | N/A | Q:30 /30Days |
VYVANSE 50 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 50MG CAPSULE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 60 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE 70MG CAPSULE |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE CAPSULES 20MG 100 BOT |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYVANSE CAPSULES 60MG 100 BOT |
4 |
Non-Preferred Drug |
45% | N/A | Q:30 /30Days |
VYXEOS 44 MG-100 MG VIAL |
5 |
Specialty Tier |
31% | N/A | P |