Q1Medicare.com 2024 Medicare Part D or Medicare Advantage Plan Formulary Browser

2024 Medicare Part D Plan Formulary Information
AARP Medicare Rx Walgreens from UHC (PDP) (S5921-403-0) Benefits & Contact Info 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 AARP Medicare Rx Walgreens from UHC (PDP) (S5921-403-0) Formulary Drugs Starting with the Letter V in CMS PDP Region 22 which includes: TX
Drugs Starting with Letter V Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter V Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VALACYCLOVIR HCL 1 GRAM TABLET [Valtrex]	3	Preferred Brand	$40.00	$120.00	Q:120 /30Days
VALACYCLOVIR HCL 500 MG TABLET [Valtrex]	3	Preferred Brand	$40.00	$120.00	Q:60 /30Days
VALCHLOR 0.016% GEL	5	Specialty Tier	27%	N/A	P Q:60 /30Days
VALGANCICLOVIR 450 MG TABLET [Valcyte]	3	Preferred Brand	$40.00	$120.00	Q:120 /30Days
VALGANCICLOVIR HCL 50 MG/ML SOLUTION RECON [Valcyte Powder]	5	Specialty Tier	27%	N/A	Q:1080 /30Days
VALPROIC ACID 250 MG CAPSULE [Depakene]	2	Generic	$8.00	$24.00	None
VALPROIC ACID 250 MG/5 ML SOLUTION [Depakene]	2	Generic	$8.00	$24.00	None
VALSARTAN 160 MG TABLET [Diovan]	2	Generic	$8.00	$24.00	Q:60 /30Days
VALSARTAN 320 MG TABLET [Diovan]	2	Generic	$8.00	$24.00	Q:30 /30Days
VALSARTAN 40 MG TABLET [Diovan]	2	Generic	$8.00	$24.00	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]	2	Generic	$8.00	$24.00	Q:60 /30Days
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]	2	Generic	$8.00	$24.00	Q:30 /30Days
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]	2	Generic	$8.00	$24.00	Q:30 /30Days
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]	2	Generic	$8.00	$24.00	Q:30 /30Days
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]	2	Generic	$8.00	$24.00	Q:30 /30Days
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]	2	Generic	$8.00	$24.00	Q:30 /30Days
VALTOCO 10 MG NASAL SPRAY	4	Non-Preferred Drug	50%	50%	P Q:10 /30Days
VALTOCO 15 MG NASAL SPRAY	4	Non-Preferred Drug	50%	50%	P Q:10 /30Days
VALTOCO 20 MG NASAL SPRAY	4	Non-Preferred Drug	50%	50%	P Q:10 /30Days
VALTOCO 5 MG NASAL SPRAY	4	Non-Preferred Drug	50%	50%	P Q:10 /30Days
VANCOMYCIN 1 GM VIAL [Vancocin]	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 500 MG VIAL	4	Non-Preferred Drug	50%	50%	None
VANCOMYCIN HCL 10 GM VIAL [Vancocin]	4	Non-Preferred Drug	50%	50%	None
VANCOMYCIN HCL 125 MG CAPSULE [Vancocin]	4	Non-Preferred Drug	50%	50%	Q:120 /30Days
VANCOMYCIN HCL 250 MG CAPSULE [Vancocin]	4	Non-Preferred Drug	50%	50%	Q:240 /30Days
VANCOMYCIN HCL 750 MG VIAL	4	Non-Preferred Drug	50%	50%	None
VANFLYTA 17.7 MG TABLET	5	Specialty Tier	27%	N/A	P Q:60 /30Days
VANFLYTA 26.5 MG TABLET	5	Specialty Tier	27%	N/A	P Q:60 /30Days
VAQTA 25 UNITS/0.5 ML SYRINGE	3	Preferred Brand	$40.00	$120.00	Q:1 /999Days
VAQTA 50 UNITS/ML SYRINGE	3	Preferred Brand	$40.00	$120.00	Q:2 /999Days
VAQTA 50 UNITS/ML VIAL	3	Preferred Brand	$40.00	$120.00	Q:2 /999Days
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL	3	Preferred Brand	$40.00	$120.00	Q:1 /999Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VARENICLINE 0.5 MG TABLET [Chantix]	4	Non-Preferred Drug	50%	50%	None
VARENICLINE 1 MG TABLET [Chantix]	4	Non-Preferred Drug	50%	50%	None
VARENICLINE STARTING MONTH BOX TABLET DS PK [Chantix]	4	Non-Preferred Drug	50%	50%	None
VARIVAX VACCINE W/DILUENT	3	Preferred Brand	$40.00	$120.00	Q:1 /1Days
VASCEPA 0.5 GM CAPSULE	3	Preferred Brand	$40.00	$120.00	None
VASCEPA 1 GM CAPSULE	3	Preferred Brand	$40.00	$120.00	None
VELPHORO 500 MG CHEWABLE TABLET	4	Non-Preferred Drug	50%	50%	None
VELTASSA 16.8 GM POWDER PACKET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VELTASSA 25.2 GM POWDER PACKET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VELTASSA 8.4 GM POWDER PACKET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VEMLIDY 25 MG TABLET	5	Specialty Tier	27%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VENCLEXTA 10 MG TABLET	3	Preferred Brand	$40.00	$120.00	P Q:14 /7Days
VENCLEXTA 100 MG TABLET	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VENCLEXTA 50 MG TABLET	5	Specialty Tier	27%	N/A	P Q:7 /7Days
VENCLEXTA STARTING PACK	5	Specialty Tier	27%	N/A	P Q:84 /365Days
VENLAFAXINE BESYLATE ER 112.5 MG TABLET 24H	4	Non-Preferred Drug	50%	50%	None
VENLAFAXINE HCL 100 MG TABLET [Effexor]	3	Preferred Brand	$40.00	$120.00	None
VENLAFAXINE HCL 25 MG TABLET [Effexor]	3	Preferred Brand	$40.00	$120.00	None
VENLAFAXINE HCL 37.5 MG TABLET [Effexor]	3	Preferred Brand	$40.00	$120.00	None
VENLAFAXINE HCL 50 MG TABLET [Effexor]	3	Preferred Brand	$40.00	$120.00	None
VENLAFAXINE HCL 75 MG TABLET [Effexor]	3	Preferred Brand	$40.00	$120.00	None
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR]	3	Preferred Brand	$40.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR]	3	Preferred Brand	$40.00	$120.00	None
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR]	3	Preferred Brand	$40.00	$120.00	None
Ventavis 0.02mg/mL	5	Specialty Tier	27%	N/A	P Q:90 /30Days
VENTAVIS 10 MCG/1 ML SOLUTION AMPUL-NEB	5	Specialty Tier	27%	N/A	P Q:210 /30Days
VENTOLIN HFA 90MCG INHALER	3	Preferred Brand	$40.00	$120.00	None
VERAPAMIL 120 MG TABLET [Calan]	1*	Preferred Generic	$2.00	$6.00	None
VERAPAMIL 40 MG TABLET [Isoptin SR]	1*	Preferred Generic	$2.00	$6.00	None
VERAPAMIL 80 MG TABLET	1*	Preferred Generic	$2.00	$6.00	None
VERAPAMIL ER 120 MG TABLET	2	Generic	$8.00	$24.00	None
VERAPAMIL ER 180 MG TABLET [Isoptin SR]	2	Generic	$8.00	$24.00	None
VERAPAMIL ER 240 MG TABLET	2	Generic	$8.00	$24.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERQUVO 10 MG TABLET	3	Preferred Brand	$40.00	$120.00	P Q:30 /30Days
VERQUVO 2.5 MG TABLET	3	Preferred Brand	$40.00	$120.00	P Q:30 /30Days
VERQUVO 5 MG TABLET	3	Preferred Brand	$40.00	$120.00	P Q:30 /30Days
VERSACLOZ 50 MG/ML ORAL SUSPENSION	4	Non-Preferred Drug	50%	50%	None
VERZENIO 100 MG TABLET	5	Specialty Tier	27%	N/A	P Q:56 /28Days
VERZENIO 150 MG TABLET	5	Specialty Tier	27%	N/A	P Q:56 /28Days
VERZENIO 200 MG TABLET	5	Specialty Tier	27%	N/A	P Q:56 /28Days
VERZENIO 50 MG TABLET	5	Specialty Tier	27%	N/A	P Q:56 /28Days
VESTURA 3 MG-0.02 MG TABLET [Yaz]	4	Non-Preferred Drug	50%	50%	None
VIBRAMYCIN 50 MG/5 ML SYRUP	4	Non-Preferred Drug	50%	50%	None
VIENVA-28 TABLET [Vienva]	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIGABATRIN 500 MG POWDER PACK [VIGADRONE]	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VIGABATRIN 500 MG TABLET [Sabril]	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VIGADRONE 500 MG POWDER PACKET	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VIGADRONE 500 MG TABLET [Sabril]	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VIGPODER 500 MG POWDER PACKET	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VILAZODONE HCL 10 MG TABLET [VIIBRYD]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VILAZODONE HCL 20 MG TABLET [VIIBRYD]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
VILAZODONE HCL 40 MG TABLET [VIIBRYD]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIRACEPT 250MG TABLET	5	Specialty Tier	27%	N/A	Q:300 /30Days
VIRACEPT 625MG TABLET	5	Specialty Tier	27%	N/A	Q:120 /30Days
VIREAD 150 MG TABLET	5	Specialty Tier	27%	N/A	Q:30 /30Days
VIREAD 200 MG TABLET	5	Specialty Tier	27%	N/A	Q:30 /30Days
VIREAD 250 MG TABLET	5	Specialty Tier	27%	N/A	Q:30 /30Days
VIREAD POWDER	5	Specialty Tier	27%	N/A	Q:240 /30Days
VITRAKVI 100 MG CAPSULE	5	Specialty Tier	27%	N/A	P Q:120 /30Days
VITRAKVI 20 MG/ML SOLUTION	5	Specialty Tier	27%	N/A	P Q:600 /30Days
VITRAKVI 25 MG CAPSULE	5	Specialty Tier	27%	N/A	P Q:180 /30Days
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL	5	Specialty Tier	27%	N/A	None
VIZIMPRO 15 MG TABLET	5	Specialty Tier	27%	N/A	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIZIMPRO 30 MG TABLET	5	Specialty Tier	27%	N/A	P Q:30 /30Days
VIZIMPRO 45 MG TABLET	5	Specialty Tier	27%	N/A	P Q:30 /30Days
VONJO 100 MG CAPSULE	5	Specialty Tier	27%	N/A	P Q:120 /30Days
VORICONAZOLE 200 MG TABLET [VFEND]	4	Non-Preferred Drug	50%	50%	Q:120 /30Days
VORICONAZOLE 200 MG VIAL [VFEND]	5	Specialty Tier	27%	N/A	P
VORICONAZOLE 40 MG/ML ORAL SUSPENSION [VFEND]	4	Non-Preferred Drug	50%	50%	Q:600 /30Days
VORICONAZOLE 50 MG TABLET [VFEND]	4	Non-Preferred Drug	50%	50%	Q:480 /30Days
VOSEVI 400-100-100 MG TABLET	5	Specialty Tier	27%	N/A	P Q:28 /28Days
VOTRIENT 200 MG TABLET	5	Specialty Tier	27%	N/A	P Q:120 /30Days
VOWST CAPSULE	5	Specialty Tier	27%	N/A	P
VRAYLAR 1.5 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VRAYLAR 1.5 MG-3 MG PACK	4	Non-Preferred Drug	50%	50%	P Q:14 /365Days
VRAYLAR 3 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P Q:30 /30Days
VRAYLAR 4.5 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P Q:30 /30Days
VRAYLAR 6 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P Q:30 /30Days
VYFEMLA 0.4 MG-0.035 MG TABLET [Zenchent]	4	Non-Preferred Drug	50%	50%	None
VYLIBRA 28 TABLET	4	Non-Preferred Drug	50%	50%	None
VYNDAMAX 61 MG CAPSULE	5	Specialty Tier	27%	N/A	P Q:30 /30Days
VYNDAQEL 20 MG CAPSULE	5	Specialty Tier	27%	N/A	P Q:120 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2024 Medicare Part D AARP Medicare Rx Walgreens from UHC (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $545 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
- Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $5,030) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
  
  *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. Please contact the drug plan for more details.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data March 2024)

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.