2022 Medicare Part D Plan Formulary Information |
Spirit Rx (HMO-POS) (H5211-004-0)
Benefit Details
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below. |
The Spirit Rx (HMO-POS) (H5211-004-0) Formulary Drugs Starting with the Letter V in Adams County, WI: CMS MA Region 14 which includes: WI
|
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 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VALACYCLOVIR HCL 1 GRAM TABLET [Valtrex] |
2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days |
VALACYCLOVIR HCL 500 MG TABLET [Valtrex] |
2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
33% | N/A | Q:60 /28Days |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:120 /30Days |
VALGANCICLOVIR HCL 50 MG/ML [Valcyte] |
5 |
Specialty Tier |
33% | N/A | Q:1080 /30Days |
VALPROIC ACID 250 MG CAPSULE [Depakene] |
2 |
Generic |
$20.00 | $60.00 | None |
VALPROIC ACID 250 MG/5 ML SOLUTION [Depakene] |
2 |
Generic |
$20.00 | $60.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days |
VALSARTAN 320 MG TABLET [Diovan] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VALSARTAN 40 MG TABLET [Diovan] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days |
VALSARTAN 80 MG TABLET [Diovan] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:30 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:30 /30Days |
VALTOCO 10 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | Q:10 /30Days |
VALTOCO 15 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | Q:10 /30Days |
VALTOCO 20 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | Q:10 /30Days |
VALTOCO 5 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | N/A | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANCOMYCIN 1 GM VIAL [Vancocin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANCOMYCIN 250 MG/5 ML SOLUTION SOLUTION RECON [Vancocin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANCOMYCIN 500 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANCOMYCIN HCL 10 GM VIAL [Vancocin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANCOMYCIN HCL 125 MG CAPSULE [Vancocin] |
2 |
Generic |
$20.00 | $60.00 | Q:80 /10Days |
VANCOMYCIN HCL 250 MG CAPSULE [Vancocin] |
2 |
Generic |
$20.00 | $60.00 | Q:80 /10Days |
VANCOMYCIN HCL 750 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2 |
Generic |
$20.00 | $60.00 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
6 |
Vaccines |
$0.00 | N/A | None |
VAQTA 50 UNITS/ML SYRINGE |
6 |
Vaccines |
$0.00 | N/A | None |
VAQTA 50 UNITS/ML VIAL |
6 |
Vaccines |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL |
6 |
Vaccines |
$0.00 | N/A | None |
VARENICLINE 0.5 MG TABLET [Chantix] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
VARENICLINE 1 MG TABLET [Chantix] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
VARENICLINE STARTING MONTH BOX TABLET DS PK [Chantix] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
VARIVAX VACCINE W/DILUENT |
6 |
Vaccines |
$0.00 | N/A | None |
VASCEPA 0.5 GM CAPSULE |
2 |
Generic |
$20.00 | $60.00 | Q:240 /30Days |
VASCEPA 1 GM CAPSULE |
2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days |
VELIVET 28 DAY TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VELPHORO 500 MG CHEWABLE TAB |
5 |
Specialty Tier |
33% | N/A | Q:180 /30Days |
VELTASSA 16.8 GM POWDER PACKET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VELTASSA 25.2 GM POWDER PACKET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VELTASSA 8.4 GM POWDER PACKET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VEMLIDY 25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VENCLEXTA 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:60 /30Days |
VENCLEXTA 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
VENCLEXTA 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days |
VENCLEXTA STARTING PACK |
5 |
Specialty Tier |
33% | N/A | P Q:42 /28Days |
VENLAFAXINE HCL 100 MG TABLET [Effexor] |
2 |
Generic |
$20.00 | $60.00 | None |
VENLAFAXINE HCL 25 MG TABLET [Effexor] |
2 |
Generic |
$20.00 | $60.00 | None |
VENLAFAXINE HCL 37.5 MG TABLET [Effexor] |
2 |
Generic |
$20.00 | $60.00 | None |
VENLAFAXINE HCL 50 MG TABLET [Effexor] |
2 |
Generic |
$20.00 | $60.00 | None |
VENLAFAXINE HCL 75 MG TABLET [Effexor] |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL ER 150 MG CAPSULE ER 24H [Effexor XR] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
VENLAFAXINE HCL ER 37.5 MG CAPSULE ER 24H [Effexor XR] |
2 |
Generic |
$20.00 | $60.00 | Q:90 /30Days |
VENLAFAXINE HCL ER 75 MG CAPSULE ER 24H [Effexor XR] |
2 |
Generic |
$20.00 | $60.00 | Q:90 /30Days |
Ventavis 0.02mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
VENTAVIS 10 MCG/1 ML SOLUTION AMPUL-NEB |
5 |
Specialty Tier |
33% | N/A | P Q:210 /30Days |
VERAPAMIL 120 MG TABLET [Calan] |
1 |
Preferred Generic |
$9.00 | $27.00 | None |
VERAPAMIL 40 MG TABLET [Isoptin SR] |
1 |
Preferred Generic |
$9.00 | $27.00 | None |
VERAPAMIL 80 MG TABLET |
1 |
Preferred Generic |
$9.00 | $27.00 | None |
VERAPAMIL ER 120 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | None |
VERAPAMIL ER 180 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | None |
VERAPAMIL ER 240 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL ER PM 100 MG CAPSULE 24H PCT [Verelan PM] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERAPAMIL ER PM 200 MG CAPSULE 24H PCT [Verelan PM] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERAPAMIL SR 120 MG CAPSULE 24H PEL [Verelan] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERAPAMIL SR 180 MG CAPSULE 24H PEL [Verelan] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERAPAMIL SR 240 MG CAPSULE 24H PEL [Verelan] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
VERQUVO 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VERQUVO 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VERQUVO 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
VERSACLOZ 50 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
33% | N/A | Q:540 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERZENIO 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
VERZENIO 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
VERZENIO 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
VERZENIO 50 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
VESTURA 3 MG-0.02 MG TABLET [Yaz] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIBERZI 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
VIBERZI 75 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days |
VIENVA-28 TABLET [Vienva] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VIGABATRIN 500 MG POWDER PACK [VIGADRONE] |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
VIGABATRIN 500 MG TABLET [Sabril] |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIGADRONE 500 MG POWDER PACKET |
5 |
Specialty Tier |
33% | N/A | Q:180 /30Days |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:45 /30Days |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:45 /30Days |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VIJOICE 125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
VIJOICE 250 MG TABLET DAILY DOSE PACK |
5 |
Specialty Tier |
33% | N/A | P Q:56 /28Days |
VIJOICE 50 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
VILAZODONE HCL 10 MG TABLET [VIIBRYD] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:45 /30Days |
VILAZODONE HCL 20 MG TABLET [VIIBRYD] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:45 /30Days |
VILAZODONE HCL 40 MG TABLET [VIIBRYD] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIMPAT 10 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1200 /30Days |
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:300 /30Days |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VIREAD POWDER |
5 |
Specialty Tier |
33% | 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 |
33% | N/A | P Q:60 /30Days |
VITRAKVI 20 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | N/A | P Q:300 /30Days |
VITRAKVI 25 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
VIZIMPRO 15 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
VIZIMPRO 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
VIZIMPRO 45 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
VONJO 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
VORICONAZOLE 200 MG TABLET [VFEND] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days |
VORICONAZOLE 200 MG VIAL [VFEND] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
VORICONAZOLE 40 MG/ML ORAL SUSPENSION [VFEND] |
5 |
Specialty Tier |
33% | N/A | P Q:400 /30Days |
VORICONAZOLE 50 MG TABLET [VFEND] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VOSEVI 400-100-100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
VOTRIENT 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
VRAYLAR 1.5 MG CAP |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VRAYLAR 3 MG CAP |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VRAYLAR 4.5 MG CAP |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VRAYLAR 6 MG CAP |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
VUITY 1.25% EYE DROPS |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:3 /25Days |
VUMERITY DR 231 MG CAPSULE DR |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
VYFEMLA 0.4 MG-0.035 MG TABLET [Zenchent] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYLIBRA 28 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYNDAMAX 61 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
VYNDAQEL 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
VYVANSE 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VYVANSE 10 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYVANSE 20 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYVANSE 30 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYVANSE 30MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VYVANSE 40 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYVANSE 40MG CAPSULE 100 EA |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VYVANSE 50 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYVANSE 50MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VYVANSE 60 MG CHEWABLE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
VYVANSE 70MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VYVANSE CAPSULES 20MG 100 BOT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VYVANSE CAPSULES 60MG 100 BOT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
VYZULTA 0.024% OPHTH SOLUTION DROPS |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:3 /25Days |