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/3ML INHALATION 1.25MG/3ML INHALATION 2 MG ORAL 2 MG/5 ML ORAL 2.5 MG/0.5 INHALATION 2.5 MG/3ML INHALATION 4 MG ORAL 5 MG/ML INHALATION ARNUITY ELLIPTA 100 MCG INHALATION 200 MCG INHALATION BUDESONIDE 0.25MG/2ML INHALATION 0.5 MG/2ML INHALATION COMBIVENT RESPIMAT 20/100 MCG INHALATION CROMOLYN SODIUM 20 MG/ML ORAL 20 MG/2 ML INHALATION 20 MG/ML ORAL DULERA 100-5 MCG INHALATION 200-5 MCG INHALATION FLOVENT HFA 44 MCG AER 110 MCG AER 220 MCG AER IPRATROPIUM-ALBUTEROL 0.5-3MG/3 INHALATION MONTELUKAST SODIUM 4 MG ORAL 5 MG ORAL 10 MG ORAL PROAIR HFA 90 MCG INHALATION QVAR REDIHALER 40 MCG INHALATION 80 MCG INHALATION SEREVENT DISKUS 50 MCG INHALATION SPIRIVA RESPIMAT 1.25 MCG INHALATION
ASTHMA SYMBICORT 80/4.5 MCG INHALATION 160/4.5 MCG INHALATION ZAFIRLUKAST 10 MG ORAL 20 MG ORAL NEBULIZERS INHALER ASSISTIVE DEVICES DIABETES BYDUREON 2 MG PEN/VIAL BYETTA 5 MCG PEN 10 MCG PEN FARXIGA 5 MG TABLET GLIMEPIRIDE 1 MG TABLET 2 MG TABLET 4 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 MG-500MG TABLET GLUCOMETER 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 1.25-250MG TABLET 2.5-500 MG TABLET 5 MG-500MG TABLET HUMALOG VIAL, CARTRIDGE, KIWKPEN HUMALOG MIX 75-25, 50-50 VIAL, KWIKPEN HUMULIN R, N VIAL, PEN 70-30 VIAL, PEN JANUMET 50MG-1000 MG TABLET 50MG-500MG TABLET JANUMET XR 50MG-1000 MG TABLET 50MG-500MG TABLET 100MG-1000MG TABLET
DIABETES JANUVIA 25 MG TABLET 50 MG TABLET 100 MG TABLET JARDIANCE 25 MG TABLET LANCETS LANTUS VIAL, SOLOSTAR PEN METFORMIN HCL 500 MG TABLET 850 MG TABLET 1000 MG TABLET NATEGLINIDE 60 MG TABLET 1 PEN NEEDLES PIOGLITAZONE HCL 15 MG TABLET 30 MG TABLET 45 MG TABLET REPAGLINIDE 0.5 MG TABLET 1 MG TABLET 2 MG TABLET SOLIQUA 100-33 PEN SYRINGES TEST STRIPS TOLBUTAMIDE 500 MG TABLET TOUJEO SOLOSTAR PEN TRULICITY 0.75 MG/0.5 ML PEN 1.5 MG/0.5 ML PEN XULTOPHY 100-3.6 PEN HYPERLIPIDEMIA ATORVASTATIN CALCIUM LOVASTATIN PRAVASTATIN SODIUM
HYPERLIPIDEMIA ROSUVASTATIN CALCIUM 5 MG TABLET HYPERTENSION AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE 5 MG-10 MG CAPSULE 5 MG-20 MG CAPSULE 5 MG-40 MG CAPSULE 10 MG-20MG CAPSULE 10 MG-40MG CAPSULE AMLODIPINE/VALSARTAN 5 MG-160MG TABLET 5 MG-320MG TABLET 10 MG-160MG TABLET 10 MG-320MG TABLET BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL/HYDROCHLOR OTHIAZIDE 5-6.25MG TABLET 10-12.5MG TABLET 20-12.5 MG TABLET 20 MG-25MG TABLET CAPTOPRIL/HYDROCHLORO THIAZIDE 25 MG-15MG TABLET 25 MG-25MG TABLET 50 MG-15MG TABLET 50 MG-25MG TABLET ENALAPRIL MALEATE 2.5 MG TABLET 5 MG TABLET ENALAPRIL/HYDROCHLORO THIAZIDE 5MG-12.5MG TABLET 10 MG-25MG TABLET FOSINOPRIL SODIUM FOSINOPRIL/HYDROCHLOR OTHIAZIDE 10-12.5MG TABLET 20-12.5 MG TABLET SIMVASTATIN 5 MG TABLET
HYPERTENSION IRBESARTAN 75 MG TABLET 150 MG TABLET 300 MG TABLET IRBESARTAN/HYDROCHLOR OTHIAZIDE 150-12.5MG TABLET 300-12.5MG TABLET LISINOPRIL 2.5 MG TABLET 30 MG TABLET LISINOPRIL/HYDROCHLORO THIAZIDE 10-12.5MG TABLET 20-12.5MG TABLET 20 MG-25MG TABLET LOSARTAN POTASSIUM 25 MG TABLET 50 MG TABLET 100 MG TABLET LOSARTAN/HYDROCHLORO THIAZIDE 50-12.5 MG TABLET 100-12.5MG TABLET 100MG-25MG TABLET MOEXIPRIL HCL 7.5 MG TABLET 15 MG TABLET MOEXIPRIL/HYDROCHLORO THIAZIDE 7.5-12.5MG TABLET 15-12.5MG TABLET 15-25MG TABLET PERINDOPRIL ERBUMINE 2 MG TABLET 4 MG TABLET 8 MG TABLET QUINAPRIL HCL 5 MG TABLET QUINAPRIL/HYDROCHLORO THIAZIDE 10-12.5MG TABLET 20-12.5 MG TABLET 20 MG-25MG TABLET RAMIPRIL 1.25 MG CAPSULE 2.5 MG CAPSULE 5 MG CAPSULE 10 MG CAPSULE TELMISARTAN TRANDOLAPRIL 1 MG TABLET 2 MG TABLET
HYPERTENSION TRANDOLAPRIL (continued) 4 MG TABLET VALSARTAN 160 MG TABLET 3 VALSARTAN/HYDROCHLOR OTHIAZIDE 80-12.5MG TABLET 160-12.5MG TABLET 160-25MG TABLET 320-12.5MG TABLET 320MG-25MG TABLET