Drug - Brand Name (Generic Name) PA Status Class Drug Notes Vabomere (meropenem / vaborbactam) - PA PA OTHER ANTIBIOTICS Vibativ (telavancin) - PA PA ANTIBIOTICS Vantas (histrelin) - PA PA HORMONE AGENTS "valoctocogene roxaparvovec-rvox CO, MB - PA" PA MISCELLANEOUS "CO, MB" Vizimpro (dacomitinib) - PA PA CHEMOTHERAPY Verzenio (abemaciclib) - PA PA CHEMOTHERAPY "voretigene neparvovec CO, MB - PA" PA OPHTHALMIC PREPARATIONS "CO, MB" voxelotor - PA PA HEMATOLOGIC Vegzelma (bevacizumab-adcd) MB - PA PA ANTINEOPLASTICS MB Vyxeos (daunorubicin / cytarabine) MB - PA PA CHEMOTHERAPY MB Vitrakvi (larotrectinib) - PA PA CHEMOTHERAPY Vonjo (pacritinib) - PA PA CHEMOTHERAPY "Votrient (pazopanib) BP, A90 - PA" PA CHEMOTHERAPY "BP, A90" vandetanib - PA PA CHEMOTHERAPY vemurafenib - PA PA CHEMOTHERAPY venetoclax - PA PA CHEMOTHERAPY Venclexta (venetoclax) - PA PA CHEMOTHERAPY vincristine liposome MB - PA PA CHEMOTHERAPY MB vismodegib - PA PA CHEMOTHERAPY Vyepti (eptinezumab-jjmr) MB - PA PA CALCITONIN GENE-RELATED PEPTIDE INHIBITOR MB Vyondys 53 (golodirsen) - PA PA BIOLOGICAL viltolarsen - PA PA BIOLOGICAL Viltepso (viltolarsen) - PA PA BIOLOGICAL valbenazine - PA PA NEUROLOGIC AGENT Valtoco (diazepam nasal spray) - PA > 10 units/30 days PA > 10 units/30 days BENZODIAZEPINES Verkazia (cyclosporine 0.1% ophthalmic emulsion) - PA PA OPHTHALMIC PREPARATIONS varenicline nasal spray - PA PA CHOLINERGIC AGONIST vericiguat - PA PA CARDIOVASCULAR Verquvo (vericiguat) - PA PA CARDIOVASCULAR Vraylar (cariprazine) PD - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC PD Versacloz (clozapine suspension) A90 - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC A90 "Valium # (diazepam solution, tablet) - PA < 6 years; See Table 69; See Table 71" PA BENZODIAZEPINES # valproic acid A90 - PA < 6 years; See Table 20; See Table 71 PA ANTICONVULSANTS "A90, #" Vyzulta (latanoprostene) - PA PA OPHTHALMIC PREPARATIONS Victoza (liraglutide-Victoza) BP - PA >9 mL/30 days PA >9 mL/30 days DIABETIC AGENTS BP Veltassa (patiromer) - PA > 1 unit/day PA > 1 unit/day CHELATING AGENT Vijoice (alpelisib-Vijoice) - PA PA UNCLASSIFIED DRUG PRODUCTS Vyjuvek (beremagene geperpavec-svdt) MB - PA PA DERMATOLOGICAL MB Veltin (clindamycin / tretinoin-Veltin) A90 - PA PA DERMATOLOGICAL A90 Vyvgart (efgartigimod alfa-fcab) MB - PA PA BIOLOGICAL MB Vyvgart Hytrulo (efgartigimod alfa-fcab and hyaluronidase-qvfc) MB - PA PA BIOLOGICAL MB Vimizim (elosulfase alfa) MB - PA PA ENZYMES MB "Vowst (fecal microbiota spores, live-brpk) - PA" PA GASTROINTESTINAL AGENT Veozah (fezolinetant) - PA PA UNCLASSIFIED DRUG PRODUCTS Vuity (pilocarpine 1.2% ophthalmic solution) - PA PA OPHTHALMIC PREPARATIONS Vesicare LS (solifenacin suspension) - PA PA ANTISPASMODIC AND ANTICHOLINERGIC AGENTS Vyndamax (tafamidis) - PA PA TRANSTHYRETIN STABILIZER Vyndaqel (tafamidis) - PA PA TRANSTHYRETIN STABILIZER Vtama (tapinarof) - PA PA DERMATOLOGICAL valsartan solution M90 - PA PA OTHER ANTIHYPERTENSIVES M90 velaglucerase alfa MB - PA PA ENZYMES MB Vpriv (velaglucerase alfa) MB - PA PA ENZYMES MB velmanase alfa-tycv MB - PA PA ENZYMES MB vestronidase alfa-vjbk MB - PA PA ENZYMES MB vibegron - PA PA ADRENERGICS voclosporin - PA PA IMMUNOMODULATOR vosoritide - PA PA UNCLASSIFIED DRUG PRODUCTS Voxzogo (vosoritide) - PA PA UNCLASSIFIED DRUG PRODUCTS "vutrisiran PD, MB - PA" PA SMALL INTERFERING RNA AGENTS "PD, MB" Vivjoa (oteseconazole) - PA PA FUNGICIDES voriconazole 50 mg tablet A90 - PA PA FUNGICIDES A90 Vfend (voriconazole 50 mg tablet) A90 - PA PA FUNGICIDES A90 Vumerity (diroximel fumarate) - PA PA MULTIPLE SCLEROSIS AGENTS Viberzi (eluxadoline) - PA PA GASTROINTESTINAL AGENT venlafaxine A90 - PA < 6 years; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 venlafaxine extended-release capsule A90 - PA < 6 years; See Table 17; See Table 71 PA ANTIDEPRESSANTS "A90, #" venlafaxine besylate extended-release tablet A90 - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 venlafaxine hydrochloride extended-release tablet A90 - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 vilazodone A90 - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 Viibryd (vilazodone) A90 - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 vortioxetine - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS vedolizumab - PA PA UNCLASSIFIED DRUG PRODUCTS "Vogelxo (testosterone 1% gel tube, packet, pump) - PA" PA HORMONE REPLACEMENT THERAPY Veletri (epoprostenol-Veletri) - PA PA CARDIOVASCULAR Ventavis (iloprost) - PA PA CARDIOVASCULAR Visco-3 (hyaluronate-Visco-3) MB - PA PA HYALURONAN MB Viread # (tenofovir disoproxil fumarate tablet) A90 - PA > 1 unit/day; See Table 38; See Table 44 PA > 1 unit/day ANTIVIRALS "A90, #" Viread (tenofovir disoproxil fumarate powder) A90 - PA ≥ 13 years; See Table 38; See Table 44 PA ≥ 13 years ANTIVIRALS A90 vorapaxar - PA PA ANTIPLATELET AGENT Vyvanse (lisdexamfetamine capsule) BP - PA 2 units/day; See Table 31; See Table 71 PA 2 units/day CEREBRAL STIMULANTS BP Vyvanse (lisdexamfetamine chewable tablet) BP - PA; See Table 31; See Table 71 PA CEREBRAL STIMULANTS BP viloxazine - PA; See Table 31; See Table 71 PA NONSTIMULANT ADHD AGENTS Viekira Pak (ombitasvir / paritaprevir / ritonavir / dasabuvir) - PA PA ANTIVIRALS Vosevi (sofosbuvir / velpatasvir / voxilaprevir) - PA PA ANTIVIRALS Veregen (sinecatechins) - PA PA ANTIVIRALS Varubi (rolapitant injection) - PA > 2 vials/28 days PA > 2 vials/28 days ANTIEMETICS Vimovo # (naproxen / esomeprazole) A90 - PA <60 years PA NONSTEROIDAL ANTI-INFLAMMATORY "A90, #" Vivlodex (meloxicam capsule) A90 - PA PA ANTIARTHRITICS A90 Vytorin # (ezetimibe / simvastatin) M90 - PA > 1 unit/day PA > 1 unit/day LIPID LOWERING AGENTS "M90, #" "Vascepa (icosapent ethyl) BP, M90 - PA" PA LIPID LOWERING AGENTS "BP, M90" "vigabatrin BP, A90 - PA" PA ANTICONVULSANTS "BP, A90" "Ventolin (albuterol inhaler-Ventolin) BP, A90" BRONCHODILATORS "BP, A90" "vitamin C (ascorbic acid) *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" Vidaza (azacitidine vial) MB CHEMOTHERAPY MB Vivimusta (bendamustine) MB CHEMOTHERAPY MB Velcade (bortezomib) MB CHEMOTHERAPY MB Vocabria (cabotegravir tablet) ANTIVIRALS "Vaxchora (cholera vaccine, live, oral)" BIOLOGICAL "vitamin B-12 (cyanocobalamin) o, M90" ELECTROLYTES AND NUTRIENTS "o, M90" Vaxelis (diphtheria / tetanus / acellular pertussis / poliovirus inactivated / haemophilus B conjugate / hepatitis B vaccine) BIOLOGICAL Vibramycin (doxycycline calcium syrup) ANTIBIOTICS Vibramycin # (doxycycline hyclate 100 mg capsule) A90 ANTIBIOTICS "A90, #" Vibramycin # (doxycycline monohydrate suspension) A90 ANTIBIOTICS "A90, #" Vasotec # (enalapril) M90 CARDIOVASCULAR "M90, #" Vaseretic # (enalapril / hydrochlorothiazide) M90 CARDIOVASCULAR "M90, #" Vagifem # (estradiol-Vagifem) M90 HORMONE REPLACEMENT THERAPY "M90, #" Vivelle-Dot # (estradiol-Vivelle-Dot) M90 HORMONE REPLACEMENT THERAPY "M90, #" Vabysmo (faricimab-svoa) MB OPHTHALMIC PREPARATIONS MB Vanos # (fluocinonide 0.1% cream) A90 GLUCOCORTICOIDS "A90, #" "Vaqta (hepatitis A vaccine, inactivated-Vaqta) 1" BIOLOGICAL 1 "Vitrase (hyaluronidase, ovine) MB" ENZYMES MB Vistaril # (hydroxyzine pamoate) A90 ANTIHISTAMINES "A90, #" Venofer (iron sucrose) MB HEMATINIC AGENT MB Vimpat # (lacosamide) A90 ANTICONVULSANTS "A90, #" Valchlor (mechlorethamine gel) CHEMOTHERAPY Vandazole (metronidazole 0.75% vaginal gel) A90 ANTIBIOTICS A90 "Vusion (miconazole / zinc oxide ointment) BP, A90" FUNGICIDES "BP, A90" Vigamox # (moxifloxacin ophthalmic solution-Vigamox) A90 OPHTHALMIC PREPARATIONS "A90, #" Vivitrol (naltrexone injection) PD ALCOHOL AND DRUG CESSATION AGENT PD Viracept (nelfinavir) ANTIVIRALS "vitamin B-3 (niacin) *, M90; See Table 6; See Table 13" ELECTROLYTES AND NUTRIENTS "*, M90" Viokace (pancrelipase-Viokace) ENZYMES Vectibix (panitumumab) MB CHEMOTHERAPY MB Vaxneuvance (pneumococcal 15-valent conjugate vaccine) BIOLOGICAL "vitamin B-6 (pyridoxine) *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" Veklury (remdesivir) MB COVID - 19 related Treatments and Vaccines MB "vitamin A (retinol) *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamin B-2 (riboflavin) *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" Vesicare # (solifenacin tablet) A90 URINARY ANTISPASMODICS "A90, #" Velphoro (sucroferric oxyhydroxide) ELECTROLYTES AND NUTRIENTS Vemlidy (tenofovir alafenamide) PD ANTIVIRALS PD "vitamin B-1 (thiamine) *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" Viroptic # (trifluridine) A90 OPHTHALMIC PREPARATIONS "A90, #" Vivotif Berna (typhoid vaccine capsule) BIOLOGICAL valacyclovir A90 ANTIVIRALS "A90, #" Valtrex # (valacyclovir) A90 ANTIVIRALS "A90, #" valganciclovir A90 ANTIVIRALS "A90, #" Valcyte # (valganciclovir) A90 ANTIVIRALS "A90, #" valproate ANTICONVULSANTS valrubicin MB CHEMOTHERAPY MB Valstar (valrubicin) MB CHEMOTHERAPY MB valsartan / hydrochlorothiazide M90 CARDIOVASCULAR "M90, #" valsartan tablet M90 CARDIOVASCULAR "M90, #" vancomycin capsule A90 ANTIBIOTICS "A90, #" Vancocin # (vancomycin capsule) A90 ANTIBIOTICS "A90, #" vancomycin injection ANTIBIOTICS "vancomycin oral solution BP, A90" ANTIBIOTICS "BP, A90" varenicline tablet A90 SMOKING CESSATION "A90, #" varicella virus vaccine 1 BIOLOGICAL 1 Varivax (varicella virus vaccine) 1 BIOLOGICAL 1 "varicella zoster immune globulin, human" BIOLOGICAL "Varizig (varicella zoster immune globulin, human)" BIOLOGICAL verapamil M90 CARDIOVASCULAR M90 verapamil extended-release M90 CARDIOVASCULAR "M90, #" Verelan PM # (verapamil extended-release) M90 CARDIOVASCULAR "M90, #" verapamil sustained-release M90 CARDIOVASCULAR "M90, #" verteporfin OPHTHALMIC PREPARATIONS Visudyne (verteporfin) OPHTHALMIC PREPARATIONS "vilobelimab COVID EUA - April 4, 2023 MB" COVID - 19 related Treatments and Vaccines MB vinblastine MB CHEMOTHERAPY MB vincristine MB CHEMOTHERAPY MB vinorelbine CHEMOTHERAPY vitamin A and D ointment * DERMATOLOGICAL * "vitamin B complex *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamin D *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamin E, oral *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamins, multiple *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamins, multiple / minerals *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamins, pediatric *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" "vitamins, prenatal *, M90" ELECTROLYTES AND NUTRIENTS "*, M90" von willebrand factor / coagulation factor VIII complex ANTI-HEMOPHILIA AGENTS "von willebrand factor, recombinant" ANTI-HEMOPHILIA AGENTS "Vonvendi (von willebrand factor, recombinant)" ANTI-HEMOPHILIA AGENTS "voriconazole injection, 200 mg tablet" FUNGICIDES # "Vfend # (voriconazole injection, 200 mg tablet)" FUNGICIDES # vorinostat CHEMOTHERAPY