2019 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0)
Benefit Details
 |
The Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $61.70 Deductible: $100 Qualifies for LIS: No |
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  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
VALACYCLOVIR HCL 500 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
VALCHLOR 0.016% GEL  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VALGANCICLOVIR 450 MG TABLET [Valcyte] ![Compare how all Medicare Part D PDP plans in FL cover VALGANCICLOVIR 450 MG TABLET [Valcyte].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | None |
VALGANCICLOVIR HCL 50 MG/ML [Valcyte] ![Compare how all Medicare Part D PDP plans in FL cover VALGANCICLOVIR HCL 50 MG/ML [Valcyte].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | None |
VALPROIC ACID 250 MG CAPSULE [Depakene] ![Compare how all Medicare Part D PDP plans in FL cover VALPROIC ACID 250 MG CAPSULE [Depakene].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | None |
VALPROIC ACID 250 MG/5 ML SOLN Solution [Depakene] ![Compare how all Medicare Part D PDP plans in FL cover VALPROIC ACID 250 MG/5 ML SOLN Solution [Depakene].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | None |
VALSARTAN 160 MG TABLET [Diovan] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN 160 MG TABLET [Diovan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
VALSARTAN 320 MG TABLET [Diovan] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN 320 MG TABLET [Diovan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN 40 MG TABLET [Diovan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 80 MG TABLET [Diovan] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN 80 MG TABLET [Diovan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT] ![Compare how all Medicare Part D PDP plans in FL cover VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VANCOMYCIN 500 MG VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VANCOMYCIN HCL 125 MG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:40 /10Days |
VANCOMYCIN HCL 250 MG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:80 /10Days |
VANCOMYCIN HCL 250 MG VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VANCOMYCIN HCL 750 MG VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | 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 |
50% | 50% | None |
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VAQTA 25 UNITS/0.5 ML SYRINGE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VAQTA 50 UNITS/ML SYRINGE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Vaqta Hepatitis A Vaccine Adult 50 Unit / mL Injection Single Dose Vial 1 mL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VARIVAX VACCINE W/DILUENT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /365Days |
VARIZIG 125 UNIT/1.2 ML VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days |
VASCEPA 0.5 GM CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:240 /30Days |
VASCEPA 1 GM CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VELIVET 28 DAY TABLET [Velivet] ![Compare how all Medicare Part D PDP plans in FL cover VELIVET 28 DAY TABLET [Velivet].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | None |
VELPHORO 500 MG CHEWABLE TAB  |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /30Days |
VELTASSA 16.8 GM POWDER PACKET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
VELTASSA 25.2 GM POWDER PACKET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
VELTASSA 8.4 GM POWDER PACKET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
VENCLEXTA 10 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:60 /30Days |
VENCLEXTA 100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
VENCLEXTA 50 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days |
VENCLEXTA STARTING PACK  |
5 |
Specialty Tier |
31% | N/A | P Q:84 /365Days |
VENLAFAXINE HCL 100 MG TABLET [Effexor] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL 100 MG TABLET [Effexor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
VENLAFAXINE HCL 25 MG TABLET [Effexor] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL 25 MG TABLET [Effexor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL 37.5 MG TABLET [Effexor] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL 37.5 MG TABLET [Effexor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
VENLAFAXINE HCL 50 MG TABLET [Effexor] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL 50 MG TABLET [Effexor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
VENLAFAXINE HCL 75 MG TABLET [Effexor] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL 75 MG TABLET [Effexor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR] ![Compare how all Medicare Part D PDP plans in FL cover VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
Ventavis 0.01mg/mL  |
5 |
Specialty Tier |
31% | N/A | P Q:270 /30Days |
Ventavis 0.02mg/mL  |
5 |
Specialty Tier |
31% | N/A | P Q:270 /30Days |
VENTOLIN HFA 90MCG INHALER  |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /30Days |
VERAPAMIL 120 MG TABLET  |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
VERAPAMIL 120MG CAP PELLET  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 180MG CAP PELLET  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VERAPAMIL 240MG CAP PELLET  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VERAPAMIL 40MG TABLET  |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
VERAPAMIL 80 MG TABLET  |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VERAPAMIL ER 120 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
VERAPAMIL ER 180 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)  |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
VERAPAMIL ER 240 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM] ![Compare how all Medicare Part D PDP plans in FL cover VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERSACLOZ 50 MG/ML ORAL SUSPENSION  |
4 |
Non-Preferred Drug |
50% | 50% | Q:540 /30Days |
VERZENIO 100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VERZENIO 150 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VERZENIO 200 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VERZENIO 50 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VESICARE 10 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
VESICARE 5 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
VIBERZI 100 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:60 /30Days |
VIBERZI 75 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:60 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:9 /30Days |
VIDEX 4 GM PEDIATRIC SOLN  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1200 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIDEX EC 125MG CAPSULE SA  |
4 |
Non-Preferred Drug |
50% | 50% | None |
VIENVA-28 TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] ![Compare how all Medicare Part D PDP plans in FL cover VIGABATRIN 500 MG ORAL TABLET [SABRIL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:180 /30Days |
VIGABATRIN 500 MG POWDER PACKET [SABRIL] ![Compare how all Medicare Part D PDP plans in FL cover VIGABATRIN 500 MG POWDER PACKET [SABRIL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:200 /30Days |
VIGABATRIN 500 MG TABLET [Sabril] ![Compare how all Medicare Part D PDP plans in FL cover VIGABATRIN 500 MG TABLET [Sabril].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:180 /30Days |
VIGADRONE 500 MG POWDER PACKET  |
5 |
Specialty Tier |
31% | N/A | P Q:200 /30Days |
VIIBRYD 10-20 MG STARTER PACK  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1200 /30Days |
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 |
50% | 50% | Q:60 /30Days |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
VIRACEPT 250MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:270 /30Days |
VIRACEPT 625MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:120 /30Days |
VIRAMUNE 50MG/5ML SUSP  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1200 /30Days |
VIREAD 150 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
VIREAD 200 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
VIREAD 250 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
VIREAD POWDER  |
5 |
Specialty Tier |
31% | N/A | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VITRAKVI 100 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
VITRAKVI 20 MG/ML SOLUTION  |
5 |
Specialty Tier |
31% | N/A | P Q:300 /30Days |
VITRAKVI 25 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:180 /30Days |
VIZIMPRO 15 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
VIZIMPRO 30 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
VIZIMPRO 45 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
VORICONAZOLE 200 MG TABLET [VFEND] ![Compare how all Medicare Part D PDP plans in FL cover VORICONAZOLE 200 MG TABLET [VFEND].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:90 /30Days |
VORICONAZOLE 200 MG VIAL  |
5 |
Specialty Tier |
31% | N/A | P |
Voriconazole 40 MG/ML Oral Suspension  |
5 |
Specialty Tier |
31% | N/A | P Q:300 /30Days |
VORICONAZOLE 50 MG TABLET [VFEND] ![Compare how all Medicare Part D PDP plans in FL cover VORICONAZOLE 50 MG TABLET [VFEND].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:90 /30Days |
VOSEVI 400-100-100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VOTRIENT 200 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
VRAYLAR 1.5 MG CAP  |
5 |
Specialty Tier |
31% | N/A | S Q:30 /30Days |
VRAYLAR 1.5 MG-3 MG PACK  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:14 /365Days |
VRAYLAR 3 MG CAP  |
5 |
Specialty Tier |
31% | N/A | S Q:30 /30Days |
VRAYLAR 4.5 MG CAP  |
5 |
Specialty Tier |
31% | N/A | S Q:30 /30Days |
VRAYLAR 6 MG CAP  |
5 |
Specialty Tier |
31% | N/A | S Q:30 /30Days |
Vyfemla 28 tablet  |
2* |
Generic |
$10.00 | $25.00 | None |
VYLIBRA 28 TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
VYTORIN 10-10 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
VYTORIN 10-20 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
VYTORIN 10-40 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYTORIN 10-80 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |