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2015 Medicare Part D Plan Formulary Information
SecureRx - Option 3 (PDP) (S8067-001-0)          
The SecureRx - Option 3 (PDP) (S8067-001-0) Formulary for Drugs Starting with the Letter V
in CMS PDP Region 6 which includes: PA WV
Plan Monthly Premium: $68.80 Deductible: $0 Qualifies for LIS:
Drugs Start 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
VAGIFEM 10 MCG VAGINAL TAB   4 Tier 4 $89.00$267.00None
VALACYCLOVIR 1000 MG ORAL TABLET   2 Tier 2 $19.00$57.00None
VALACYCLOVIR 500 MG ORAL TABLET   2 Tier 2 $19.00$57.00None
VALCHLOR 0.016% GEL   5 Tier 5 33%N/AP
VALCYTE 450MG TABLET   5 Tier 5 33%N/ANone
VALCYTE FOR ORAL SOLUTION 50MG/ML   5 Tier 5 33%N/ANone
VALGANCICLOVIR 450 MG TABLET [Valcyte]   5 Tier 5 33%N/ANone
VALPROATE SODIUM 500 mg/5 ml vl   2 Tier 2 $19.00$57.00None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE   2 Tier 2 $19.00$57.00None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE   2 Tier 2 $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VALSARTAN 160 MG TABLET [Diovan]   1 Tier 1 $4.00$12.00Q:60/30Days
VALSARTAN 320 MG TABLET [Diovan]   1 Tier 1 $4.00$12.00None
VALSARTAN 40 MG TABLET [Diovan]   1 Tier 1 $4.00$12.00Q:60/30Days
VALSARTAN 80 MG TABLET [Diovan]   1 Tier 1 $4.00$12.00Q:60/30Days
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]   1 Tier 1 $4.00$12.00Q:30/30Days
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]   1 Tier 1 $4.00$12.00Q:30/30Days
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]   1 Tier 1 $4.00$12.00None
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]   1 Tier 1 $4.00$12.00None
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]   1 Tier 1 $4.00$12.00Q:30/30Days
VANCOMYCIN HCL 125 MG CAPSULE   5 Tier 5 33%N/ANone
VANCOMYCIN HCL 250 MG CAPSULE   5 Tier 5 33%N/ANone
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 Tier 2 $19.00$57.00P
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   2 Tier 2 $19.00$57.00P
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE)   2 Tier 2 $19.00$57.00P
VANDAZOLE 0.75% GEL WITH APPLICATOR   2 Tier 2 $19.00$57.00None
VAQTA 25 UNITS/0.5ML SYRINGE   3 Tier 3 $40.00$120.00None
VAQTA 25 UNITS/0.5ML VIAL   3 Tier 3 $40.00$120.00None
VAQTA 50 UNITS/ML SYRINGE   3 Tier 3 $40.00$120.00None
VARIVAX VACCINE W/DILUENT   3 Tier 3 $40.00$120.00None
VASCEPA 1 GM CAPSULE   4 Tier 4 $89.00$267.00None
VELCADE 3.5MG VIAL   5 Tier 5 33%N/AP
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   2 Tier 2 $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VENLAFAXINE HCL 100MG TABLET   2 Tier 2 $19.00$57.00None
VENLAFAXINE HCL 25MG TABLET   2 Tier 2 $19.00$57.00None
VENLAFAXINE HCL 37.5MG TABLET   2 Tier 2 $19.00$57.00None
VENLAFAXINE HCL 50MG TABLET   2 Tier 2 $19.00$57.00None
VENLAFAXINE HCL 75MG TABLET   2 Tier 2 $19.00$57.00None
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE   2 Tier 2 $19.00$57.00Q:60/30Days
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE   2 Tier 2 $19.00$57.00Q:30/30Days
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE   2 Tier 2 $19.00$57.00Q:30/30Days
VERAPAMIL 120MG CAP PELLET   2 Tier 2 $19.00$57.00None
VERAPAMIL 180MG CAP PELLET   2 Tier 2 $19.00$57.00None
VERAPAMIL 2.5MG/ML AMPUL   2 Tier 2 $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERAPAMIL 240MG CAP PELLET   2 Tier 2 $19.00$57.00None
VERAPAMIL 40MG TABLET   1 Tier 1 $4.00$12.00None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   2 Tier 2 $19.00$57.00None
VERAPAMIL ER 120 MG TABLET   2 Tier 2 $19.00$57.00None
VERAPAMIL ER 180 MG TABLET   2 Tier 2 $19.00$57.00None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   2 Tier 2 $19.00$57.00None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS   2 Tier 2 $19.00$57.00None
VERAPAMIL HCL 120MG TABLET   1 Tier 1 $4.00$12.00None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   2 Tier 2 $19.00$57.00None
VERAPAMIL HCL 80MG TABLET   1 Tier 1 $4.00$12.00None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Tier 2 $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERSACLOZ 50 MG/ML SUSPENSION   5 Tier 5 33%N/AP Q:600/30Days
VESICARE 10MG TABLET   4 Tier 4 $89.00$267.00Q:30/30Days
VESICARE 5MG TABLET (90 CT)   4 Tier 4 $89.00$267.00Q:30/30Days
Vestura 3 mg-0.02 mg tablet   2 Tier 2 $19.00$57.00None
VIBRAMYCIN 50MG/5ML SYRUP   4 Tier 4 $89.00$267.00None
VICTOZA 3-PAK 18 MG/3 ML PEN   3 Tier 3 $40.00$120.00Q:9/30Days
VICTRELIS 200mg/1 4 TRAY per CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE BOTTLE   5 Tier 5 33%N/AP
VIDEX 2GM PEDIATRIC TUBEX   4 Tier 4 $89.00$267.00None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]   5 Tier 5 33%N/AP Q:180/30Days
VIGABATRIN 500 MG ORAL TABLET [SABRIL]   5 Tier 5 33%N/AP Q:180/30Days
VIGAMOX 0.5% EYE DROPS   3 Tier 3 $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIIBRYD 1 KIT per BLISTER PACK   4 Tier 4 $89.00$267.00None
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   4 Tier 4 $89.00$267.00Q:30/30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   4 Tier 4 $89.00$267.00Q:30/30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   4 Tier 4 $89.00$267.00Q:30/30Days
VIMPAT 10 MG/ML SOLUTION   4 Tier 4 $89.00$267.00Q:1200/30Days
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $89.00$267.00Q:60/30Days
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS   4 Tier 4 $89.00$267.00None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $89.00$267.00Q:60/30Days
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $89.00$267.00Q:60/30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $89.00$267.00Q:180/30Days
VINBLASTINE 1 MG/ML VIAL   3 Tier 3 $40.00$120.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VINCRISTINE 1MG/ML VIAL   2 Tier 2 $19.00$57.00P
VINCRISTINE 1MG/ML VIAL   2 Tier 2 $19.00$57.00P
VINORELBINE 10MG/ML VIAL 5ML VIAL   2 Tier 2 $19.00$57.00P
VIRACEPT 250MG TABLET   5 Tier 5 33%N/ANone
VIRACEPT 625MG TABLET   5 Tier 5 33%N/ANone
VIRAMUNE XR 100 MG TABLET   4 Tier 4 $89.00$267.00None
VIREAD 150 MG TABLET   5 Tier 5 33%N/ANone
VIREAD 200 MG TABLET   5 Tier 5 33%N/ANone
VIREAD 250 MG TABLET   5 Tier 5 33%N/ANone
VIREAD 300MG TABLET   5 Tier 5 33%N/ANone
VIREAD POWDER   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VITEKTA 150 MG TABLET   5 Tier 5 33%N/ANone
VITEKTA 85 MG TABLET   5 Tier 5 33%N/ANone
VOLTAREN 1% GEL   3 Tier 3 $40.00$120.00None
VORICONAZOLE 200 MG VIAL   2 Tier 2 $19.00$57.00None
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Tier 5 33%N/ANone
Voriconazole 40 mg/ml susp   5 Tier 5 33%N/ANone
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Tier 5 33%N/ANone
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE   5 Tier 5 33%N/AP
Vyfemla 28 tablet   2 Tier 2 $19.00$57.00None
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Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2015 Medicare Part D SecureRx - Option 3 (PDP) Plan Formulary.
.

  • Plan Name: This is the official Medicare Part D prescription drug 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).

  • 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 the standard $320 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 wit 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 which tier the drug is in. 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2015 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 June 2015 )

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 Part D plan provider.