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2014 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: $64.30 Deductible: $0 Qualifies for LIS: No
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
VALACYCLOVIR 1000 MG ORAL TABLET   2 Non-Preferred Generic $19.00$57.00None
VALACYCLOVIR 500 MG ORAL TABLET   2 Non-Preferred Generic $19.00$57.00None
VALCYTE 450MG TABLET   4 Specialty Tier 33%N/ANone
VALCYTE FOR ORAL SOLUTION 50MG/ML   4 Specialty Tier 33%N/ANone
Valproate Sodium 100mg/mL 10 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE   2 Non-Preferred Generic $19.00$57.00None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE   2 Non-Preferred Generic $19.00$57.00None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic $19.00$57.00None
VALSARTAN-HCTZ 160-12.5 MG TAB   2 Non-Preferred Generic $19.00$57.00Q:60/30Days
VALSARTAN-HCTZ 160-25 MG TAB   2 Non-Preferred Generic $19.00$57.00Q:60/30Days
VALSARTAN-HCTZ 320-12.5 MG TAB   2 Non-Preferred Generic $19.00$57.00Q:60/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VALSARTAN-HCTZ 320-25 MG TAB   2 Non-Preferred Generic $19.00$57.00Q:60/30Days
VALSARTAN-HCTZ 80-12.5 MG TAB   2 Non-Preferred Generic $19.00$57.00Q:60/30Days
VANCOCIN HCL 125MG PULVULE   4 Specialty Tier 33%N/ANone
VANCOCIN HCL 250MG PULVULE   4 Specialty Tier 33%N/ANone
VANCOMYCIN HCL 125 MG CAPSULE   4 Specialty Tier 33%N/ANone
VANCOMYCIN HCL 250 MG CAPSULE   4 Specialty Tier 33%N/ANone
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )   2 Non-Preferred Generic $19.00$57.00None
Vancomycin Hydrochloride 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   2 Non-Preferred Generic $19.00$57.00None
VANCOMYCIN HYDROCHLORIDE INJECTION (STERILE)   3 Preferred Brand $40.00$120.00None
VANDAZOLE 0.75% GEL WITH APPLICATOR   2 Non-Preferred Generic $19.00$57.00None
VAQTA 25 UNITS/0.5ML VIAL   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VARIVAX VACCINE W/DILUENT   3 Preferred Brand $40.00$120.00None
VELCADE 3.5MG VIAL   4 Specialty Tier 33%N/AP
Velivet Triphasic Regimen 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HCL 100MG TABLET   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HCL 25MG TABLET   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HCL 37.5MG TABLET   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HCL 50MG TABLET   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HCL 75MG TABLET   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $19.00$57.00None
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ventavis 0.01mg/mL   4 Specialty Tier 33%N/AP
Ventavis 0.02mg/mL   4 Specialty Tier 33%N/AP
VERAPAMIL 120MG CAP PELLET   2 Non-Preferred Generic $19.00$57.00None
VERAPAMIL 180MG CAP PELLET   2 Non-Preferred Generic $19.00$57.00None
VERAPAMIL 2.5MG/ML AMPUL   2 Non-Preferred Generic $19.00$57.00None
VERAPAMIL 240MG CAP PELLET   2 Non-Preferred Generic $19.00$57.00None
VERAPAMIL 40MG TABLET   1 Preferred Generic $5.00$15.00None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   2 Non-Preferred Generic $19.00$57.00None
VERAPAMIL ER 180 MG TABLET   1 Preferred Generic $5.00$15.00None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   2 Non-Preferred Generic $19.00$57.00None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS   2 Non-Preferred Generic $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERAPAMIL HCL 120MG TABLET   1 Preferred Generic $5.00$15.00None
VERAPAMIL HCL 80MG TABLET   1 Preferred Generic $5.00$15.00None
VERAPAMIL HCL CAPSULES SUSTAINED RELEASE   2 Non-Preferred Generic $19.00$57.00None
Verapamil Hydrochloride 120mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTEN   1 Preferred Generic $5.00$15.00None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Preferred Generic $5.00$15.00None
VESICARE 10MG TABLET   3 Preferred Brand $40.00$120.00None
VESICARE 5MG TABLET (90 CT)   3 Preferred Brand $40.00$120.00None
Vestura 3 mg-0.02 mg tablet   2 Non-Preferred Generic $19.00$57.00None
VICTRELIS 200mg/1 4 TRAY in 1 CARTON / 7 BOTTLE in 1 TRAY / 12 CAPSULE in 1 BOTTLE   4 Specialty Tier 33%N/AP
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU   4 Specialty Tier 33%N/AP
VIDEX 2GM PEDIATRIC TUBEX   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]   4 Specialty Tier 33%N/ANone
VIGABATRIN 500 MG ORAL TABLET [SABRIL]   4 Specialty Tier 33%N/ANone
VIIBRYD 1 KIT in 1 BLISTER PACK   3 Preferred Brand $40.00$120.00S
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $40.00$120.00S
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $40.00$120.00S
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $40.00$120.00S
VIMPAT 10 MG/ML SOLUTION   3 Preferred Brand $40.00$120.00None
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $40.00$120.00None
Vimpat 10mg/mL 10 VIAL, GLASS in 1 CARTON / 20 mL in 1 VIAL, GLASS   3 Preferred Brand $40.00$120.00None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $40.00$120.00None
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $40.00$120.00None
VIRACEPT 250MG TABLET   3 Preferred Brand $40.00$120.00None
VIRACEPT 625MG TABLET   3 Preferred Brand $40.00$120.00None
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand $40.00$120.00None
VIRAMUNE 50MG/5ML SUSP   3 Preferred Brand $40.00$120.00None
VIRAMUNE XR 100 MG TABLET   3 Preferred Brand $40.00$120.00None
VIREAD 150 MG TABLET   4 Specialty Tier 33%N/ANone
VIREAD 200 MG TABLET   4 Specialty Tier 33%N/ANone
VIREAD 250 MG TABLET   4 Specialty Tier 33%N/ANone
VIREAD 300MG TABLET   3 Preferred Brand $40.00$120.00None
VIREAD POWDER   4 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL   4 Specialty Tier 33%N/ANone
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Specialty Tier 33%N/ANone
Voriconazole 40 mg/ml susp   4 Specialty Tier 33%N/ANone
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Specialty Tier 33%N/ANone
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE   4 Specialty Tier 33%N/ANone
Vyfemla 28 tablet   2 Non-Preferred Generic $19.00$57.00None



What does all this mean? Here are a few notes to help you understand the above 2014 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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 August 2014 )

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.