2009 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Premier (S5810-203-0)
Benefit Details
|
The Aetna Medicare Rx Premier (S5810-203-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 33 which includes: HI
|
Drugs Starting with Letter Z
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ZALEPLON 10MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:2 /1Days |
ZALEPLON 5MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:4 /1Days |
ZAMICET SOLN 325MG; 10MG/15ML |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANAFLEX 2MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANAFLEX 4MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANAFLEX 4MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANAFLEX 6MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANOSAR 1GM VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANTAC 150MG GRANULES |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANTAC 150MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZANTAC 15MG/ML SYRUP |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANTAC 25 EFFERDOSE TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANTAC 25MG/ML VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANTAC 300MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZANTAC 50MG/50ML PLAST-BAG |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZARONTIN 250MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZARONTIN 250MG/5ML SYRUP |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZAROXOLYN 10MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZAROXOLYN 2.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZAROXOLYN 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZAVESCA 100MG CAPSULE |
5 |
Tier 5 - Specialty |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZAZOLE 0.8% CREAM WITH APPLICATOR |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZEBETA 10MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
ZEBETA 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
ZEGERID 20MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZEGERID 20MG PACKET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZEGERID 40MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZEGERID 40MG PACKET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZELAPAR 1.25MG ODT TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZEMAIRA 1000MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZEMPLAR 1 MCG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZEMPLAR 2 MCG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZEMPLAR 2 MCG/ML VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZEMPLAR 4 MCG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZEMPLAR 5MCG/ML VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZENAPAX 5MG/ML VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
ZERIT 15MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZERIT 1MG/ML SOLUTION |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZERIT 20MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZERIT 30MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZERIT 40MG CAPSULE |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZERLOR TABLET 712.8MG/60MG |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZESTORETIC 10/12.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZESTORETIC 20/12.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZESTORETIC 20/25MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZESTRIL 10MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZESTRIL 2.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZESTRIL 20MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZESTRIL 30MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZESTRIL 40MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZESTRIL 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZETIA 10MG TABLET (90 CT) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZIAC 10-6.25MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZIAC 5-6.25MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZIAGEN 20MG/ML SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZIAGEN 300MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZIANA 1.2-0.025% GEL TOPICAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZIDOVUDINE 100MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZIDOVUDINE 10MG/ML SYRUP |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZIDOVUDINE 300MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZINACEF 1.5GM VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZINACEF 7.5GM VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZINACEF 750MG VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZINACEF ADD VTG FOR INJECTION 750MG 10 VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZINACEF INJECTION ADD VANTAGE 1.5GM 10 VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZINACEF/DEXTROSE 750MG/50ML |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZINACEF/WATER 1.5GM/50ML |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZINECARD 250MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
ZINECARD 500MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
ZITHROMAX 1GM POWDER PACKET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX 250MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX 500MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX 600MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX ORAL SUSP 200MG/5ML |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZMAX 2 G/60ML SUSP SR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZOCOR 10MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZOCOR 20MG TABLET (90 CT) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZOCOR 40MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZOCOR 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZOCOR 80MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOFRAN 2MG/ML MDV VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S |
ZOFRAN 4MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S Q:6 /1Days |
ZOFRAN 4MG/5ML ORAL TUBEX |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S Q:30 /1Days |
ZOFRAN 8MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S Q:3 /1Days |
ZOFRAN ODT 4MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S Q:6 /1Days |
ZOFRAN ODT 8MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P S Q:3 /1Days |
ZOLINZA 100MG CAPSULE |
5 |
Tier 5 - Specialty |
33% | 33% | P Q:4 /1Days |
ZOLOFT 100MG TABLET (30 CT) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:2 /1Days |
ZOLOFT 20MG/ML ORAL CONC |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:10 /1Days |
ZOLOFT 25MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
ZOLOFT 50MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOLPIDEM TARTRATE 10MG TABLET (500 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:1 /1Days |
ZOLPIDEM TARTRATE 5MG TABLET (500 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:2 /1Days |
ZOMETA 4MG/5ML VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | None |
ZOMIG 2.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:6 /30Days |
ZOMIG 5MG NASAL SPRAY |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:6 /30Days |
ZOMIG 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:6 /30Days |
ZOMIG ZMT 2.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:6 /30Days |
ZOMIG ZMT 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:6 /30Days |
ZONALON 5% CREAM |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZONEGRAN 100MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
ZONEGRAN 25MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZONISAMIDE 100MG CAPSULE (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZONISAMIDE 25MG CAPSULE (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZONISAMIDE 50MG CAPSULE (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZORBTIVE 8.8MG VIAL |
5 |
Tier 5 - Specialty |
33% | 33% | P |
ZOSTAVAX VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | P Q:1 /365Days |
ZOSYN 2/0.25GM PRE-MIX BAG |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZOSYN 2/0.25GRAM VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZOSYN 3/0.375GRAM VIAL 1 VIAL SU |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZOSYN 36/4.5GRAM BULK VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZOSYN 4/0.5GM PRE-MIX BAG |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOSYN 4/0.5GRAM VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZOVIA 1/35-28 TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZOVIA 1/50-28 TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
ZOVIRAX 200MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZOVIRAX 200MG/5ML ORAL SUSP |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZOVIRAX 400MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZOVIRAX 5% CREAM |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZOVIRAX 5% OINTMENT |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZOVIRAX 800MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZYBAN 150MG TABLET SA |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:2 /1Days |
ZYDONE 10/400MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYDONE 5/400MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
ZYDONE 7.5/400MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | S |
ZYFLO CR 600MG TABLET MULTIPHASIC RELEASE 12HR |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | Q:4 /1Days |
ZYLET 0.3%-0.5% SUSPENSION DROPS(FINAL DOSAGE FORM)(ML) |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZYLOPRIM 100MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZYLOPRIM 300MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZYMAR 0.3% EYE DROPS |
4 |
Tier 4 - Non-Preferred Brand |
$65.00 | $130.00 | None |
ZYPREXA 10MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA 10MG VIAL |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | None |
ZYPREXA 15MG TABLET (1000 BOT) |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA 2.5MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA 20MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA 5MG TABLET (30 BOT) |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA 7.5MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA ZYDIS 10MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA ZYDIS 15MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA ZYDIS 20MG TABLET |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK) |
3 |
Tier 3 - Preferred Brand |
$30.00 | $60.00 | Q:1 /1Days |
ZYVOX 100MG/5ML SUSPENSION |
5 |
Tier 5 - Specialty |
33% | 33% | P |
ZYVOX 600MG TABLET |
5 |
Tier 5 - Specialty |
33% | 33% | P |
ZYVOX 600MG/300ML IV SOLUTION |
5 |
Tier 5 - Specialty |
33% | 33% | P |