THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
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1 Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual review, and may be added to or removed from the list at the sole discretion of the Board of Directors of the Virginia Private Colleges Benefits Consortium, Inc. at any time without prior notice to Covered Person. Therefore, please access the current list of Value Based Tier Drugs at or by calling, toll free, (844) The online list supersedes any previous online or printed lists. ASTHMA ALBUTEROL 0.63MG/3 ML INHALATION 1.25MG/3 ML INHALATION 2 MG/5 ML ORAL 2.5 MG/0.5 ML INHALATION 2.5 MG/3 ML INHALATION 5 MG/ML INHALATION ARNUITY ELLIPTA 100 MCG INHALATION 200 MCG INHALATION BUDESONIDE 0.25MG/2 ML INHALATION 0.5 MG/2 ML INHALATION COMBIVENT RESPIMAT 20/100 MCG INHALATION CROMOLYN SODIUM 20 MG/ML ORAL 20 MG/2 ML INHALATION DULERA MCG INHALATION MCG INHALATION FLOVENT HFA 44 MCG AEROSOL 110 MCG AEROSOL 220 MCG AEROSOL IPRATROPIUM-ALBUTEROL 0.5-3MG/3 ML INHALATION MONTELUKAST SODIUM 4 MG ORAL 5 MG ORAL 10 MG ORAL PROAIR HFA 90 MCG INHALATION QVAR 40 MCG INHALATION 80 MCG INHALATION
2 ASTHMA SEREVENT DISKUS 50 MCG INHALATION SPIRIVA RESPIMAT 1.25 MCG INHALATION SYMBICORT 80/4.5 MCG INHALATION 160/4.5 MCG INHALATION ZAFIRLUKAST 10 MG ORAL 20 MG ORAL NEBULIZERS INHALER ASSISTIVE DEVICES DIABETES GLIMEPIRIDE 1 MG TABLET GLIPIZIDE 2.5 MG TAB ER 24 5 MG TAB ER 24 TABLET 10 MG TAB ER 24 TABLET GLIPIZIDE/METFORMIN HCL MG TABLET MG TABLET 5-500MG TABLET GLYBURIDE 1.25 MG TABLET 2.5 MG TABLET 5 MG TABLET GLYBURIDE, MICRONIZED 1.5 MG TABLET 3 MG TABLET 6 MG TABLET GLYBURIDE/METFORMIN HCL MG TABLET MG TABLET MG TABLET METFORMIN HCL 500 MG TABLET 850 MG TABLET 1000 MG TABLET NATEGLINIDE 60 MG TABLET 1 PIOGLITAZONE HCL 15 MG TABLET 30 MG TABLET 45 MG TABLET REPAGLINIDE 0.5 MG TABLET 1 MG TABLET TOLBUTAMIDE 500 MG TABLET HUMALOG VIAL, CARTRIDGE, KIWKPEN
3 DIABETES HUMALOG MIX 75-25, VIAL, KWIKPEN HUMULIN R, N VIAL, PEN VIAL, PEN LANTUS VIAL, SOLOSTAR PEN XULTOPHY PEN TOUJEO SOLOSTAR PEN SOLIQUA PEN LANCETS SYRINGES PEN NEEDLES FREESTYLE GLUCOMETER FREESTYLE & PRECISION TEST STRIPS HYPERLIPIDEMIA ATORVASTATIN CALCIUM LOVASTATIN PRAVASTATIN SODIUM ROSUVASTATIN CALCIUM 5 MG TABLET SIMVASTATIN 5 MG TABLET HYPERTENSION AMLODIPINE BESYLATE/BENAZEPRIL MG CAPSULE 5-10 MG CAPSULE 5-20 MG CAPSULE 5-40 MG CAPSULE MG CAPSULE MG CAPSULE AMLODIPINE/VALSARTAN MG TABLET MG TABLET
4 HYPERTENSION AMLODIPINE/VALSARTAN continued 10-3 BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET CAPTOPRIL/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET MG TABLET MG TABLET ENALAPRIL MALEATE 2.5 MG TABLET 5 MG TABLET ENALAPRIL/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET FOSINOPRIL SODIUM FOSINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET IRBESARTAN 75 MG TABLET 150 MG TABLET 300 MG TABLET IRBESARTAN/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET LISINOPRIL 2.5 MG TABLET 30 MG TABLET LISINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET LOSARTAN POTASSIUM 25 MG TABLET 50 MG TABLET 100 MG TABLET LOSARTAN/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET
5 HYPERTENSION LOSARTAN/HYDROCHLOROTHIAZIDE MG TABLET MOEXIPRIL HCL 7.5 MG TABLET 15 MG TABLET MOEXIPRIL/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET MG TABLET PERINDOPRIL ERBUMINE 8 MG TABLET QUINAPRIL HCL 5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE MG TABLET RAMIPRIL 1.25 MG CAPSULE 2.5 MG CAPSULE 5 MG CAPSULE 10 MG CAPSULE TELMISARTAN TRANDOLAPRIL 1 MG TABLET VALSARTAN 160 MG TABLET 3 VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET MG TABLET MG TABLET MG TABLET
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
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