2023 Medicare Part D Plan Formulary Information |
Keystone 65 Select Rx (HMO) (H3952-049-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Keystone 65 Select Rx (HMO) (H3952-049-0) Formulary Drugs Starting with the Letter V in Philadelphia County, PA: CMS MA Region 6 which includes: PA
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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 [Valtrex] |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:90 /30Days |
VALACYCLOVIR HCL 500 MG TABLET [Valtrex] |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days |
VALCHLOR 0.016% GEL |
5 |
Specialty Tier |
33% | 33% | P |
VALGANCICLOVIR 450 MG TABLET [Valcyte] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VALGANCICLOVIR HCL 50 MG/ML SOLUTION RECON [Valcyte Powder] |
5 |
Specialty Tier |
33% | 33% | None |
VALPROIC ACID 250 MG CAPSULE [Depakene] |
2 |
Generic |
$7.00 | $14.00 | None |
VALPROIC ACID 250 MG/5 ML SOLUTION [Depakene] |
2 |
Generic |
$7.00 | $14.00 | None |
VALSARTAN 160 MG TABLET [Diovan] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
VALSARTAN 320 MG TABLET [Diovan] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN 40 MG TABLET [Diovan] |
1 |
Preferred Generic |
$0.00 | $0.00 | 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] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT] |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
VALTOCO 10 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:10 /30Days |
VALTOCO 15 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:10 /30Days |
VALTOCO 20 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:10 /30Days |
VALTOCO 5 MG NASAL SPRAY |
5 |
Specialty Tier |
33% | 33% | P Q:10 /30Days |
VANCOMYCIN 1 GM VIAL [Vancocin] |
2 |
Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VANCOMYCIN 25 MG/ML ORAL SOLUTION RECON [FIRVANQ] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VANCOMYCIN 250 MG/5 ML SOLUTION SOLUTION RECON [Vancocin] |
2 |
Generic |
$7.00 | $14.00 | None |
VANCOMYCIN 500 MG VIAL |
2 |
Generic |
$7.00 | $14.00 | None |
VANCOMYCIN HCL 10 GM VIAL [Vancocin] |
2 |
Generic |
$7.00 | $14.00 | None |
VANCOMYCIN HCL 125 MG CAPSULE [Vancocin] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VANCOMYCIN HCL 250 MG CAPSULE [Vancocin] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VANCOMYCIN HCL 750 MG VIAL |
2 |
Generic |
$7.00 | $14.00 | None |
VANDAZOLE 0.75% GEL WITH APPLICATOR |
2 |
Generic |
$7.00 | $14.00 | None |
VAQTA 25 UNITS/0.5 ML SYRINGE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VAQTA 50 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VAQTA 50 UNITS/ML VIAL |
3 |
Preferred Brand |
$47.00 | $94.00 | 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 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VARENICLINE 0.5 MG TABLET [Chantix] |
2 |
Generic |
$7.00 | $14.00 | None |
VARENICLINE 1 MG TABLET [Chantix] |
2 |
Generic |
$7.00 | $14.00 | None |
VARENICLINE STARTING MONTH BOX TABLET DS PK [Chantix] |
2 |
Generic |
$7.00 | $14.00 | None |
VARIVAX VACCINE W/DILUENT |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VARUBI 90 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P |
VASCEPA 0.5 GM CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VASCEPA 1 GM CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VECAMYL 2.5 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VELIVET 28 DAY TABLET |
2 |
Generic |
$7.00 | $14.00 | None |
VELTASSA 16.8 GM POWDER PACKET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VELTASSA 25.2 GM POWDER PACKET |
5 |
Specialty Tier |
33% | 33% | None |
VELTASSA 8.4 GM POWDER PACKET |
5 |
Specialty Tier |
33% | 33% | None |
VEMLIDY 25 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
VENCLEXTA 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:60 /30Days |
VENCLEXTA 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
VENCLEXTA 50 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
VENCLEXTA STARTING PACK |
5 |
Specialty Tier |
33% | 33% | P Q:84 /365Days |
VENLAFAXINE BESYLATE ER 112.5 MG TABLET 24H |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:30 /30Days |
VENLAFAXINE HCL 100 MG TABLET [Effexor] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 25 MG TABLET [Effexor] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 37.5 MG TABLET [Effexor] |
2 |
Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VENLAFAXINE HCL 50 MG TABLET [Effexor] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL 75 MG TABLET [Effexor] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 150 MG TABLET 24H [Venlafaxine] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 225 MG TABLET 24H [Venlafaxine] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 37.5 MG TABLET 24H |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR] |
2 |
Generic |
$7.00 | $14.00 | None |
VENLAFAXINE HCL ER 75 MG TABLET 24H [Venlafaxine] |
2 |
Generic |
$7.00 | $14.00 | None |
Ventavis 0.02mg/mL |
5 |
Specialty Tier |
33% | 33% | P Q:270 /30Days |
VENTAVIS 10 MCG/1 ML SOLUTION AMPUL-NEB |
5 |
Specialty Tier |
33% | 33% | P Q:270 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL 120 MG TABLET [Calan] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL 40 MG TABLET [Isoptin SR] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL 80 MG TABLET |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL ER 120 MG TABLET |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL ER 180 MG TABLET [Isoptin SR] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL ER 240 MG TABLET |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL ER PM 100 MG CAPSULE 24H PCT [Verelan PM] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL ER PM 200 MG CAPSULE 24H PCT [Verelan PM] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
VERAPAMIL SR 120 MG CAPSULE 24H PEL [Verelan] |
2 |
Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VERAPAMIL SR 180 MG CAPSULE 24H PEL [Verelan] |
2 |
Generic |
$7.00 | $14.00 | None |
VERAPAMIL SR 240 MG CAPSULE 24H PEL [Verelan] |
2 |
Generic |
$7.00 | $14.00 | None |
VEREGEN 15% OINTMENT |
5 |
Specialty Tier |
33% | 33% | None |
VERQUVO 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VERQUVO 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VERQUVO 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VERSACLOZ 50 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
33% | 33% | None |
VERZENIO 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VERZENIO 150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VERZENIO 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VERZENIO 50 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VESTURA 3 MG-0.02 MG TABLET [Yaz] |
2 |
Generic |
$7.00 | $14.00 | None |
VIBERZI 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
VIBERZI 75 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
VICTOZA 3-PAK 18 MG/3 ML PEN |
3 |
Preferred Brand |
$47.00 | $94.00 | S Q:9 /30Days |
VIENVA-28 TABLET [Vienva] |
2 |
Generic |
$7.00 | $14.00 | None |
VIGABATRIN 500 MG ORAL TABLET [SABRIL] |
5 |
Specialty Tier |
33% | 33% | None |
VIGABATRIN 500 MG POWDER PACK [VIGADRONE] |
5 |
Specialty Tier |
33% | 33% | None |
VIGABATRIN 500 MG TABLET [Sabril] |
5 |
Specialty Tier |
33% | 33% | None |
VIGADRONE 500 MG POWDER PACKET |
5 |
Specialty Tier |
33% | 33% | None |
VIIBRYD 10-20 MG STARTER PACK |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S |
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S |
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S |
VIJOICE 125 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
VIJOICE 250 MG TABLET DAILY DOSE PACK |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
VIJOICE 50 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
VILAZODONE HCL 10 MG TABLET [VIIBRYD] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VILAZODONE HCL 20 MG TABLET [VIIBRYD] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VILAZODONE HCL 40 MG TABLET [VIIBRYD] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VIMOVO 375-20 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
VIMOVO 500-20 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
VIMPAT 10 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |
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 |
5 |
Specialty Tier |
33% | 33% | None |
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | None |
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | None |
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VIOKACE 10,440-39,150 UNIT TABLET |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VIOKACE 20,880-78,300 UNIT TABLET |
5 |
Specialty Tier |
33% | 33% | None |
VIRACEPT 250MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:270 /30Days |
VIRACEPT 625MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:120 /30Days |
VIREAD 150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
VIREAD 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
VIREAD 250 MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VIREAD POWDER |
5 |
Specialty Tier |
33% | 33% | None |
VITRAKVI 100 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
VITRAKVI 20 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | P |
VITRAKVI 25 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL |
5 |
Specialty Tier |
33% | 33% | None |
VIZIMPRO 15 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VIZIMPRO 30 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VIZIMPRO 45 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VONJO 100 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
VORICONAZOLE 200 MG TABLET [VFEND] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VORICONAZOLE 200 MG VIAL [VFEND] |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VORICONAZOLE 40 MG/ML ORAL SUSPENSION [VFEND] |
5 |
Specialty Tier |
33% | 33% | None |
VORICONAZOLE 50 MG TABLET [VFEND] |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None |
VOSEVI 400-100-100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VOTRIENT 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
VOXZOGO 0.4 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
VOXZOGO 0.56 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
VOXZOGO 1.2 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
VRAYLAR 1.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | S Q:30 /30Days |
VRAYLAR 1.5 MG-3 MG PACK |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:14 /365Days |
VRAYLAR 3 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | S Q:30 /30Days |
VRAYLAR 4.5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
VRAYLAR 6 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | S Q:30 /30Days |
VUITY 1.25% EYE DROPS |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P |
VUMERITY DR 231 MG CAPSULE DR |
5 |
Specialty Tier |
33% | 33% | S |
VYFEMLA 0.4 MG-0.035 MG TABLET [Zenchent] |
2 |
Generic |
$7.00 | $14.00 | None |
VYLIBRA 28 TABLET |
2 |
Generic |
$7.00 | $14.00 | None |
VYNDAMAX 61 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
VYNDAQEL 20 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |