Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (S5678-016-0) Benefit Details
The Health Net Orange Option 1 (S5678-016-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 5 which includes: DC DE MD
Drugs Starting with Letter Z Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter Z Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZALEPLON 10MG CAPSULE	1	Preferred Generic	$2.00	$4.00	S Q:1 /1Days
ZALEPLON 5MG CAPSULE	1	Preferred Generic	$2.00	$4.00	S Q:1 /1Days
ZANOSAR 1GM VIAL	4	Injectable	25%	N/A	None
ZANTAC 150MG GRANULES	2	Preferred Brand	$45.00	$90.00	None
ZANTAC 150MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZANTAC 15MG/ML SYRUP	2	Preferred Brand	$45.00	$90.00	None
ZANTAC 25 EFFERDOSE TABLET	2	Preferred Brand	$45.00	$90.00	None
ZANTAC 25MG/ML VIAL	4	Injectable	25%	N/A	None
ZANTAC 300MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZANTAC 50MG/50ML PLAST-BAG	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZARONTIN 250MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZARONTIN 250MG/5ML SYRUP	2	Preferred Brand	$45.00	$90.00	None
ZAROXOLYN 10MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZAROXOLYN 2.5MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZAROXOLYN 5MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZAVESCA 100MG CAPSULE	5	Specialty	25%	N/A	P
ZAZOLE 0.4% CREAM WITH APPLICATOR	1	Preferred Generic	$2.00	$4.00	None
ZAZOLE 0.8% CREAM WITH APPLICATOR	3	Non-Preferred Brand	$90.00	$225.00	None
ZAZOLE 80MG SUPPOSITORY VAGINAL	1	Preferred Generic	$2.00	$4.00	None
ZEBETA 10MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZEBETA 5MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZEMAIRA 1000MG VIAL	5	Specialty	25%	N/A	P
ZEMPLAR 2 MCG/ML VIAL	4	Injectable	25%	N/A	None
ZEMPLAR 5MCG/ML VIAL	4	Injectable	25%	N/A	None
ZENAPAX 5MG/ML VIAL	5	Specialty	25%	N/A	P
ZERIT 15MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZERIT 1MG/ML SOLUTION	2	Preferred Brand	$45.00	$90.00	None
ZERIT 20MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZERIT 30MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZERIT 40MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZERLOR TABLET 712.8MG/60MG	3	Non-Preferred Brand	$90.00	$225.00	None
ZESTORETIC 10/12.5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZESTORETIC 20/12.5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:4 /1Days
ZESTORETIC 20/25MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZESTRIL 10MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZESTRIL 2.5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZESTRIL 20MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZESTRIL 30MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZESTRIL 40MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZESTRIL 5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZETIA 10MG TABLET (90 CT)	2	Preferred Brand	$45.00	$90.00	None
ZIAC 10-6.25MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZIAC 2.5-6.25MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZIAC 5-6.25MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZIAGEN 20MG/ML SOLUTION	2	Preferred Brand	$45.00	$90.00	None
ZIAGEN 300MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZIDOVUDINE 100MG CAPSULE	1	Preferred Generic	$2.00	$4.00	None
ZIDOVUDINE 10MG/ML SYRUP	1	Preferred Generic	$2.00	$4.00	None
ZIDOVUDINE 300MG TABLET	1	Preferred Generic	$2.00	$4.00	None
ZINACEF 1.5GM VIAL	4	Injectable	25%	N/A	None
ZINACEF 7.5GM VIAL	4	Injectable	25%	N/A	None
ZINACEF 750MG VIAL	4	Injectable	25%	N/A	None
ZINACEF ADD VTG FOR INJECTION 750MG 10 VIAL	4	Injectable	25%	N/A	None
ZINACEF INJECTION ADD VANTAGE 1.5GM 10 VIAL	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZINACEF/DEXTROSE 750MG/50ML	4	Injectable	25%	N/A	None
ZINACEF/WATER 1.5GM/50ML	4	Injectable	25%	N/A	None
ZINECARD 250MG VIAL	4	Injectable	25%	N/A	None
ZINECARD 500MG VIAL	4	Injectable	25%	N/A	None
ZITHROMAX 1GM POWDER PACKET	2	Preferred Brand	$45.00	$90.00	Q:2 /5Days
ZITHROMAX 250MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:6 /5Days
ZITHROMAX 250MG Z-PAK TABLET	2	Preferred Brand	$45.00	$90.00	Q:6 /5Days
ZITHROMAX 500MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:3 /3Days
ZITHROMAX 600MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:8 /28Days
ZITHROMAX IV 500MG VIAL 10 VIAL BOX	4	Injectable	25%	N/A	None
ZITHROMAX ORAL SUSP 100MG/5ML	2	Preferred Brand	$45.00	$90.00	Q:15 /5Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZITHROMAX ORAL SUSP 200MG/5ML	2	Preferred Brand	$45.00	$90.00	Q:30 /5Days
ZITHROMAX TRI-PAK 500MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:3 /3Days
ZMAX 2 G/60ML SUSP SR	3	Non-Preferred Brand	$90.00	$225.00	Q:2 /1Days
ZOCOR 10MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOCOR 20MG TABLET (90 CT)	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOCOR 40MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOCOR 5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOCOR 80MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOFRAN 2MG/ML MDV VIAL	4	Injectable	25%	N/A	P
ZOFRAN 4MG TABLET	2	Preferred Brand	$45.00	$90.00	P
ZOFRAN 4MG/5ML ORAL TUBEX	2	Preferred Brand	$45.00	$90.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZOFRAN 8MG TABLET	2	Preferred Brand	$45.00	$90.00	P
ZOFRAN ODT 4MG TABLET	2	Preferred Brand	$45.00	$90.00	P
ZOFRAN ODT 8MG TABLET	2	Preferred Brand	$45.00	$90.00	P
ZOLINZA 100MG CAPSULE	5	Specialty	25%	N/A	P
ZOLOFT 100MG TABLET (30 CT)	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZOLOFT 20MG/ML ORAL CONC	2	Preferred Brand	$45.00	$90.00	Q:10 /1Days
ZOLOFT 25MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOLOFT 50MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZOLPIDEM TARTRATE 10MG TABLET (500 CT)	1	Preferred Generic	$2.00	$4.00	Q:1 /1Days
ZOLPIDEM TARTRATE 5MG TABLET (500 CT)	1	Preferred Generic	$2.00	$4.00	Q:1 /1Days
ZOMETA 4MG/5ML VIAL	5	Specialty	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZONALON 5% CREAM	2	Preferred Brand	$45.00	$90.00	None
ZONEGRAN 100MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZONEGRAN 25MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZONISAMIDE 100MG CAPSULE (100 CT)	1	Preferred Generic	$2.00	$4.00	None
ZONISAMIDE 25MG CAPSULE (100 CT)	1	Preferred Generic	$2.00	$4.00	None
ZONISAMIDE 50MG CAPSULE (100 CT)	1	Preferred Generic	$2.00	$4.00	None
ZORBTIVE 8.8MG VIAL	5	Specialty	25%	N/A	P
ZOSTAVAX VIAL	4	Injectable	25%	N/A	None
ZOSYN 2/0.25GM PRE-MIX BAG	4	Injectable	25%	N/A	None
ZOSYN 2/0.25GRAM VIAL	4	Injectable	25%	N/A	None
ZOSYN 3/0.375GRAM 24 BAGS PKG	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZOSYN 3/0.375GRAM VIAL 1 VIAL SU	4	Injectable	25%	N/A	None
ZOSYN 36/4.5GRAM BULK VIAL	4	Injectable	25%	N/A	None
ZOSYN 4/0.5GM PRE-MIX BAG	4	Injectable	25%	N/A	None
ZOSYN 4/0.5GRAM VIAL	4	Injectable	25%	N/A	None
ZOVIA 1/35-28 TABLET	1	Preferred Generic	$2.00	$4.00	Q:1 /1Days
ZOVIA 1/50-28 TABLET	1	Preferred Generic	$2.00	$4.00	Q:1 /1Days
ZOVIRAX 200MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
ZOVIRAX 200MG/5ML ORAL SUSP	2	Preferred Brand	$45.00	$90.00	None
ZOVIRAX 400MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZOVIRAX 5% CREAM	2	Preferred Brand	$45.00	$90.00	None
ZOVIRAX 5% OINTMENT	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZOVIRAX 800MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZYBAN 150MG TABLET SA	2	Preferred Brand	$45.00	$90.00	P
ZYFLO CR 600MG TABLET MULTIPHASIC RELEASE 12HR	2	Preferred Brand	$45.00	$90.00	P Q:4 /1Days
ZYLET 0.3%-0.5% SUSPENSION DROPS(FINAL DOSAGE FORM)(ML)	2	Preferred Brand	$45.00	$90.00	Q:15 /10Days
ZYLOPRIM 100MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZYLOPRIM 300MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ZYMAR 0.3% EYE DROPS	3	Non-Preferred Brand	$90.00	$225.00	None
ZYPREXA 10MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZYPREXA 10MG VIAL	4	Injectable	25%	N/A	None
ZYPREXA 15MG TABLET (1000 BOT)	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZYPREXA 2.5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZYPREXA 20MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZYPREXA 5MG TABLET (30 BOT)	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
ZYPREXA 7.5MG TABLET	2	Preferred Brand	$45.00	$90.00	Q:1 /1Days
ZYPREXA ZYDIS 10MG TABLET	2	Preferred Brand	$45.00	$90.00	P Q:2 /1Days
ZYPREXA ZYDIS 15MG TABLET	2	Preferred Brand	$45.00	$90.00	P Q:1 /1Days
ZYPREXA ZYDIS 20MG TABLET	2	Preferred Brand	$45.00	$90.00	P Q:1 /1Days
ZYPREXA ZYDIS 5MG TABLET (30 BLPK)	2	Preferred Brand	$45.00	$90.00	P Q:2 /1Days
ZYVOX 600MG/300ML IV SOLUTION	5	Specialty	25%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Health Net Orange Option 1 Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.