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 https://mp.medimpact.com/vpcbc or by calling, toll free, (844) 401-1903. 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 100-5 MCG INHALATION 200-5 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
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 2.5-250 MG TABLET 2.5-500 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 1.25-250 MG TABLET 2.5-500 MG TABLET 5-500 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
DIABETES HUMALOG MIX 75-25, 50-50 VIAL, KWIKPEN HUMULIN R, N VIAL, PEN 70-30 VIAL, PEN LANTUS VIAL, SOLOSTAR PEN XULTOPHY 100-3.6 PEN TOUJEO SOLOSTAR PEN SOLIQUA 100-33 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 2.5-10 MG CAPSULE 5-10 MG CAPSULE 5-20 MG CAPSULE 5-40 MG CAPSULE 10-20 MG CAPSULE 10-40 MG CAPSULE AMLODIPINE/VALSARTAN 5-160 MG TABLET 5-3 10-160 MG TABLET
HYPERTENSION AMLODIPINE/VALSARTAN continued 10-3 BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25 MG TABLET 10-12.5 MG TABLET CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-15 MG TABLET 25-25 MG TABLET 50-15 MG TABLET 50-25 MG TABLET ENALAPRIL MALEATE 2.5 MG TABLET 5 MG TABLET ENALAPRIL/HYDROCHLOROTHIAZIDE 5-12.5 MG TABLET 10-25 MG TABLET FOSINOPRIL SODIUM FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5 MG TABLET IRBESARTAN 75 MG TABLET 150 MG TABLET 300 MG TABLET IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5 MG TABLET 300-12.5 MG TABLET LISINOPRIL 2.5 MG TABLET 30 MG TABLET LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5 MG TABLET LOSARTAN POTASSIUM 25 MG TABLET 50 MG TABLET 100 MG TABLET LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5 MG TABLET 100-12.5 MG TABLET
HYPERTENSION LOSARTAN/HYDROCHLOROTHIAZIDE 100-25 MG TABLET MOEXIPRIL HCL 7.5 MG TABLET 15 MG TABLET MOEXIPRIL/HYDROCHLOROTHIAZIDE 7.5-12.5 MG TABLET 15-12.5 MG TABLET 15-25 MG TABLET PERINDOPRIL ERBUMINE 8 MG TABLET QUINAPRIL HCL 5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5 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 80-12.5 MG TABLET 160-12.5 MG TABLET 160-25 MG TABLET 3 320-25MG TABLET