2019 Medicare Part D Plan Formulary Information |
Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Benefit Details
|
The Express Scripts Medicare - Choice (PDP) (S5660-181-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $98.90 Deductible: $350 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 |
2* |
Generic |
$7.00 | $4.00 | Q:120 /30Days |
VALACYCLOVIR HCL 500 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
26% | N/A | P |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VALGANCICLOVIR HCL 50 MG/ML [Valcyte] |
5 |
Specialty Tier |
26% | N/A | None |
VALPROIC ACID 250 MG CAPSULE [Depakene] |
2* |
Generic |
$7.00 | $4.00 | None |
VALPROIC ACID 250 MG/5 ML SOLN Solution [Depakene] |
2* |
Generic |
$7.00 | $4.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
VALSARTAN 320 MG TABLET [Diovan] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 80 MG TABLET [Diovan] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT] |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT] |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT] |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT] |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT] |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
VANCOMYCIN 500 MG VIAL |
4 |
Non-Preferred Drug |
36% | N/A | None |
VANCOMYCIN HCL 125 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:120 /30Days |
VANCOMYCIN HCL 250 MG CAPSULE |
5 |
Specialty Tier |
26% | N/A | Q:240 /30Days |
VANCOMYCIN HCL 250 MG VIAL |
4 |
Non-Preferred Drug |
36% | N/A | None |
VANCOMYCIN HCL 750 MG VIAL |
4 |
Non-Preferred Drug |
36% | 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 ) |
2* |
Generic |
$7.00 | $4.00 | None |
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA |
4 |
Non-Preferred Drug |
36% | N/A | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2* |
Generic |
$7.00 | $4.00 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Vaqta Hepatitis A Vaccine Adult 50 Unit / mL Injection Single Dose Vial 1 mL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VARIZIG 125 UNIT/1.2 ML VIAL |
5 |
Specialty Tier |
26% | N/A | None |
VASCEPA 0.5 GM CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VASCEPA 1 GM CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VELIVET 28 DAY TABLET [Velivet] |
2* |
Generic |
$7.00 | $4.00 | None |
VELTASSA 16.8 GM POWDER PACKET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VELTASSA 25.2 GM POWDER PACKET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VELTASSA 8.4 GM POWDER PACKET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VEMLIDY 25 MG TABLET |
5 |
Specialty Tier |
26% | N/A | None |
VENCLEXTA 10 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:60 /30Days |
VENCLEXTA 100 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:120 /30Days |
VENCLEXTA 50 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VENCLEXTA STARTING PACK |
4 |
Non-Preferred Drug |
36% | N/A | P Q:42 /28Days |
VENLAFAXINE HCL 100 MG TABLET [Effexor] |
2* |
Generic |
$7.00 | $4.00 | Q:90 /30Days |
VENLAFAXINE HCL 25 MG TABLET [Effexor] |
2* |
Generic |
$7.00 | $4.00 | 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] |
2* |
Generic |
$7.00 | $4.00 | Q:90 /30Days |
VENLAFAXINE HCL 50 MG TABLET [Effexor] |
2* |
Generic |
$7.00 | $4.00 | Q:90 /30Days |
VENLAFAXINE HCL 75 MG TABLET [Effexor] |
2* |
Generic |
$7.00 | $4.00 | Q:90 /30Days |
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR] |
2* |
Generic |
$7.00 | $4.00 | Q:90 /30Days |
Ventavis 0.01mg/mL |
4 |
Non-Preferred Drug |
36% | N/A | P |
Ventavis 0.02mg/mL |
4 |
Non-Preferred Drug |
36% | N/A | P |
VERAPAMIL 120 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL 120MG CAP PELLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL 180MG CAP PELLET |
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 240MG CAP PELLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL 40MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL 80 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL ER 120 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
VERAPAMIL ER 180 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT) |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL ER 240 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
VERSACLOZ 50 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
26% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERZENIO 100 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:60 /30Days |
VERZENIO 150 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:60 /30Days |
VERZENIO 200 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:60 /30Days |
VERZENIO 50 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:60 /30Days |
VESICARE 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VESICARE 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VICODIN 5-300 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | Q:360 /30Days |
VICODIN ES 7.5-300 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | Q:360 /30Days |
VICODIN HP 10-300 MG TABLET [Xodol] |
4 |
Non-Preferred Drug |
36% | N/A | Q:360 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:9 /30Days |
VIDEX 4 GM PEDIATRIC SOLN |
4 |
Non-Preferred Drug |
36% | N/A | 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 |
36% | N/A | Q:90 /30Days |
VIENVA-28 TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
26% | N/A | P Q:180 /30Days |
VIGABATRIN 500 MG POWDER PACKET [SABRIL] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:180 /30Days |
VIGABATRIN 500 MG TABLET [Sabril] |
5 |
Specialty Tier |
26% | N/A | P Q:180 /30Days |
VIGADRONE 500 MG POWDER PACKET |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:180 /30Days |
VIIBRYD 10-20 MG STARTER PACK |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /180Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
VIMPAT 10 MG/ML SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | 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 |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
VIOKACE 10,440-39,150 UNITS TB |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
VIOKACE 20,880-78,300 UNITS TB |
5 |
Specialty Tier |
26% | N/A | None |
VIRACEPT 250MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | Q:270 /30Days |
VIRACEPT 625MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | Q:120 /30Days |
VIRAMUNE 50MG/5ML SUSP |
4 |
Non-Preferred Drug |
36% | N/A | Q:1200 /30Days |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
26% | N/A | Q:30 /30Days |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
26% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
26% | N/A | Q:30 /30Days |
VIREAD POWDER |
5 |
Specialty Tier |
26% | N/A | Q:225 /30Days |
VITRAKVI 100 MG CAPSULE |
4 |
Non-Preferred Drug |
36% | N/A | P |
VITRAKVI 20 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
36% | N/A | P |
VITRAKVI 25 MG CAPSULE |
4 |
Non-Preferred Drug |
36% | N/A | P |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
5 |
Specialty Tier |
26% | N/A | None |
VIZIMPRO 15 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VIZIMPRO 30 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VIZIMPRO 45 MG TABLET |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VORICONAZOLE 200 MG TABLET [VFEND] |
5 |
Specialty Tier |
26% | N/A | None |
VORICONAZOLE 200 MG VIAL |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Voriconazole 40 MG/ML Oral Suspension |
5 |
Specialty Tier |
26% | N/A | None |
VORICONAZOLE 50 MG TABLET [VFEND] |
5 |
Specialty Tier |
26% | N/A | None |
VOTRIENT 200 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:120 /30Days |
VRAYLAR 1.5 MG CAP |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Drug |
36% | N/A | P Q:7 /30Days |
VRAYLAR 3 MG CAP |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VRAYLAR 4.5 MG CAP |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
VRAYLAR 6 MG CAP |
4 |
Non-Preferred Drug |
36% | N/A | P Q:30 /30Days |
Vyfemla 28 tablet |
2* |
Generic |
$7.00 | $4.00 | None |
VYLIBRA 28 TABLET |
2* |
Generic |
$7.00 | $4.00 | None |