2020 Medicare Part D Plan Formulary Information |
Kaiser Permanente Medicare Advantage Optimal (HMO) (H5050-004-0)
Benefit Details
|
The Kaiser Permanente Medicare Advantage Optimal (HMO) (H5050-004-0) Formulary Drugs Starting with the Letter V in Lewis County, WA: CMS MA Region 23 which includes: WA Plan Monthly Premium: $295.00 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 |
VABOMERE 2 GRAM VIAL |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VALACYCLOVIR HCL 1 GRAM TABLET [Valtrex] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALACYCLOVIR HCL 500 MG TABLET [Valtrex] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALCHLOR 0.016% GEL |
5 |
Tier 5 |
33% | N/A | None |
VALCYTE 450MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALGANCICLOVIR HCL 50 MG/ML [Valcyte] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALPROIC ACID 250 MG CAPSULE [Depakene] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALPROIC ACID 250 MG/5 ML SOLN Solution [Depakene] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 320 MG TABLET [Diovan] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN 40 MG TABLET [Diovan] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN 80 MG TABLET [Diovan] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VALTOCO 10 MG NASAL SPRAY |
5 |
Tier 5 |
33% | N/A | None |
VALTOCO 15 MG NASAL SPRAY |
5 |
Tier 5 |
33% | N/A | None |
VALTOCO 20 MG NASAL SPRAY |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALTOCO 5 MG NASAL SPRAY |
5 |
Tier 5 |
33% | N/A | None |
VANATOL LQ ORAL SOLUTION |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VANCOCIN HCL 125 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
VANCOCIN HCL 250 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
VANCOMYCIN 1 GM VIAL [Vancocin] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VANCOMYCIN 250 MG/5 ML SOLUTION RECON [Vancocin] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VANCOMYCIN 500 MG VIAL |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VANCOMYCIN HCL 125 MG CAPSULE [Vancocin] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VANCOMYCIN HCL 250 MG CAPSULE [Vancocin] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VANCOMYCIN HCL 250 MG VIAL |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VANCOMYCIN HCL 750 MG VIAL |
2 |
Tier 2 |
$7.00 | $14.00 | 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 |
Tier 2 |
$7.00 | $14.00 | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
6 |
Tier 6 |
$0.00 | N/A | None |
VAQTA 50 UNITS/ML SYRINGE |
6 |
Tier 6 |
$0.00 | N/A | None |
VAQTA 50 UNITS/ML VIAL |
6 |
Tier 6 |
$0.00 | N/A | None |
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL |
6 |
Tier 6 |
$0.00 | N/A | None |
VARIVAX VACCINE W/DILUENT |
6 |
Tier 6 |
$0.00 | N/A | None |
VARIZIG 125 UNIT/1.2 ML VIAL |
6 |
Tier 6 |
$0.00 | N/A | None |
VARUBI 90 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | P |
VASCEPA 0.5 GM CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VASCEPA 1 GM CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VECAMYL 2.5 MG TABLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VELIVET 28 DAY TABLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
5 |
Tier 5 |
33% | N/A | None |
VELTASSA 16.8 GM POWDER PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VELTASSA 25.2 GM POWDER PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VELTASSA 8.4 GM POWDER PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VEMLIDY 25 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VENCLEXTA 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VENCLEXTA 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VENCLEXTA 50 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENCLEXTA STARTING PACK |
5 |
Tier 5 |
33% | N/A | None |
VENLAFAXINE HCL 100 MG TABLET [Effexor] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 25 MG TABLET [Effexor] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 37.5 MG TABLET [Effexor] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 50 MG TABLET [Effexor] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 75 MG TABLET [Effexor] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 150 MG TABLET ER 24 [Venlafaxine] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 225 MG TABLET ER 24 [Venlafaxine] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 37.5 MG CAPSULE ER 24H [Effexor XR] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 37.5 MG TABLET ER 24 [Venlafaxine] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL ER 75 MG CAPSULE ER 24H [Effexor XR] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 75 MG TABLET ER 24 [Venlafaxine] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
Ventavis 0.02mg/mL |
5 |
Tier 5 |
33% | N/A | P |
VENTAVIS 10 MCG/1 ML SOLUTION AMPUL-NEB |
5 |
Tier 5 |
33% | N/A | P |
VENTOLIN HFA 90MCG INHALER |
2 |
Tier 2 |
$7.00 | $14.00 | Q:36 /30Days |
VERAPAMIL 120 MG TABLET [Calan] |
1 |
Tier 1 |
$3.00 | $0.00 | None |
VERAPAMIL 120MG CAPSULE PELLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL 180MG CAPSULE PELLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL 240MG CAPSULE PELLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL 40 MG TABLET [Isoptin SR] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL 80 MG TABLET |
1 |
Tier 1 |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL ER 120 MG TABLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL ER 180 MG TABLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL ER 240 MG TABLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL ER PM 100 MG CAPSULE 24H PCT [Verelan PM] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL ER PM 200 MG CAPSULE 24H PCT [Verelan PM] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VEREGEN 15% OINTMENT |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VERELAN 360 MG CAPSULE PELLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VERSACLOZ 50 MG/ML ORAL SUSPENSION |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VERZENIO 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERZENIO 150 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VERZENIO 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VERZENIO 50 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VFEND 200MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VFEND 40MG/ML SUSPENSION |
5 |
Tier 5 |
33% | N/A | None |
VFEND 50MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VIBERZI 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VIBERZI 75 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VIBRAMYCIN 50MG/5ML SYRUP |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VIEKIRA PAK |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIENVA-28 TABLET [Vienva] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] |
5 |
Tier 5 |
33% | N/A | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Tier 5 |
33% | N/A | None |
VIGABATRIN 500 MG POWDER PACKET [VIGADRONE] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VIGABATRIN 500 MG TABLET [Sabril] |
5 |
Tier 5 |
33% | N/A | None |
VIGADRONE 500 MG POWDER PACKET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIMOVO 375-20 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIMOVO 500-20 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIMPAT 10 MG/ML SOLUTION |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIOKACE 10,440-39,150 UNITS TB |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIOKACE 20,880-78,300 UNITS TB |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIRACEPT 250MG TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VIRACEPT 625MG TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VIRAMUNE 200MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIRAMUNE 50MG/5ML SUSP |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIREAD 150 MG TABLET |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VIREAD 200 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIREAD 250 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIREAD 300MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIREAD POWDER |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VITRAKVI 100 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
VITRAKVI 20 MG/ML SOLUTION |
5 |
Tier 5 |
33% | N/A | None |
VITRAKVI 25 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIVLODEX 10 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIVLODEX 5 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VIZIMPRO 15 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VIZIMPRO 30 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VIZIMPRO 45 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
VORICONAZOLE 200 MG TABLET [VFEND] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VORICONAZOLE 200 MG VIAL |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VORICONAZOLE 40 MG/ML ORAL SUSPENSION [VFEND] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VORICONAZOLE 50 MG TABLET [VFEND] |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VOSEVI 400-100-100 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
VOTRIENT 200 MG TABLET |
5 |
Tier 5 |
33% | 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 |
Tier 5 |
33% | N/A | P |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Tier 4 |
$95.00 | $190.00 | P |
VRAYLAR 3 MG CAP |
5 |
Tier 5 |
33% | N/A | P |
VRAYLAR 4.5 MG CAP |
5 |
Tier 5 |
33% | N/A | P |
VRAYLAR 6 MG CAP |
5 |
Tier 5 |
33% | N/A | P |
VTOL LQ 50-325-40 MG/15 ML SOLUTION |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VUMERITY DR 231 MG CAPSULE DR |
5 |
Tier 5 |
33% | N/A | P |
Vyfemla 28 tablet |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VYLIBRA 28 TABLET |
2 |
Tier 2 |
$7.00 | $14.00 | None |
VYNDAMAX 61 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
VYNDAQEL 20 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYVANSE 10 MG CAPSULE |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VYVANSE 10 MG CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VYVANSE 20 MG CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VYVANSE 30 MG CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VYVANSE 30MG CAPSULE |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VYVANSE 40 MG CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VYVANSE 40MG CAPSULE 100 EA |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VYVANSE 50 MG CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VYVANSE 50MG CAPSULE |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VYVANSE 60 MG CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
VYVANSE 70MG CAPSULE |
3 |
Tier 3 |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYVANSE CAPSULES 20MG 100 BOT |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VYVANSE CAPSULES 60MG 100 BOT |
3 |
Tier 3 |
$45.00 | $90.00 | None |
VYZULTA 0.024% OPHTH SOLUTION |
4 |
Tier 4 |
$95.00 | $190.00 | P |