2012 Medicare Part D Plan Formulary Information |
Asuris Medicare Script Basic (PDP) (S5609-001-0)
Benefit Details
|
The Asuris Medicare Script Basic (PDP) (S5609-001-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 30 which includes: OR WA
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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 |
ZAFIRLUKAST TABLETS |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZAFIRLUKAST TABLETS |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZALEPLON 10MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZALEPLON 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZANAFLEX 2MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANAFLEX 4MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANAFLEX 4MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANAFLEX 6MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANOSAR 1GM VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
ZANTAC 150MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZANTAC 15MG/ML SYRUP |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANTAC 25 EFFERDOSE TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANTAC 25MG/ML VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
ZANTAC 300MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZANTAC 50MG/50ML PLAST-BAG |
6 |
Injectable Drugs |
28% | N/A | None |
ZARONTIN 250MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZARONTIN 250MG/5ML SYRUP |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZAROXOLYN 2.5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZAROXOLYN 5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZAVESCA 100MG CAPSULE |
5 |
Specialty Tier Drugs |
28% | N/A | P Q:90 /30Days |
ZAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZAZOLE 0.8% CREAM WITH APPLICATOR |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
Zebeta 10mg/1 30 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZEBETA 5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZELAPAR 1.25MG ODT TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZELBORAF 240mg/1 1 BOTTLE, PLASTIC in 1 CARTON / 120 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
5 |
Specialty Tier Drugs |
28% | N/A | P Q:240 /30Days |
ZEMAIRA 1000MG VIAL |
5 |
Specialty Tier Drugs |
28% | N/A | None |
ZEMPLAR 1 MCG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P |
ZEMPLAR 2 MCG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P |
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE |
6 |
Injectable Drugs |
28% | N/A | P |
ZEMPLAR 4 MCG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P |
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE |
6 |
Injectable Drugs |
28% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENPEP 109000; 20000; 68000[USP'U]/1; [USP'U]/1; [USP'U]/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZENPEP 27000; 5000; 17000[USP'U]/1; [USP'U]/1; [USP'U]/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE, |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZENPEP 55000; 10000; 34000[USP'U]/1; [USP'U]/1; [USP'U]/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE, |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZENPEP 82000; 15000; 51000[USP'U]/1; [USP'U]/1; [USP'U]/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE, |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZENPEP DR 25,000 UNITS CAPSULE |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZENPEP DR 3,000 UNITS CAPSULE |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZERIT 15MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZERIT 1MG/ML SOLUTION |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZERIT 20MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZERIT 30MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZERIT 40MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZERLOR TABLET 712.8MG/60MG |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZESTORETIC 12.5; 20mg/1; mg/1 |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTORETIC TABLETS |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTORETIC TABLETS |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTRIL 10mg/1 100 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTRIL 2.5mg/1 |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTRIL 5mg/1 100 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTRIL TABLETS |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTRIL TABLETS 20MG 100 BOT |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZESTRIL TABLETS 40 MG |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZETIA 10MG TABLET (90 CT) |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZIAC 10-6.25MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZIAC 5-6.25MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZIAGEN 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZIANA 1.2-0.025% GEL TOPICAL |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZIDOVUDINE 100MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZIDOVUDINE 10MG/ML SYRUP |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
Zidovudine 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZINACEF 7.5GM VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
ZINACEF ADD VTG FOR INJECTION 750MG 10 VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZINACEF INJECTION ADD VANTAGE 1.5GM 10 VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
ZINACEF/DEXTROSE 750MG/50ML |
6 |
Injectable Drugs |
28% | N/A | None |
ZINACEF/WATER 1.5GM/50ML |
6 |
Injectable Drugs |
28% | N/A | None |
ZINECARD 250 MG VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
ZIPRASIDONE HCL 20 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZIPRASIDONE HCL 40 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZIPRASIDONE HCL 60 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZIPRASIDONE HCL 80 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZITHROMAX 250MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZITHROMAX 500MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX 600MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
6 |
Injectable Drugs |
28% | N/A | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZITHROMAX ORAL SUSP 200MG/5ML |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZMAX 2g/60mL 60 mL in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZOLINZA 100MG CAPSULE |
5 |
Specialty Tier Drugs |
28% | N/A | P Q:120 /30Days |
Zolpidem Tartrate 5mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZOLPIDEM TARTRATE TABLETS |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZOLPIDEM TARTRATE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
ZOLPIDEM TARTRATE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zometa 4mg/100mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
6 |
Injectable Drugs |
28% | N/A | P |
ZOMETA 4MG/5ML VIAL |
6 |
Injectable Drugs |
28% | N/A | P |
ZOMIG 2.5 MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P Q:12 /30Days |
ZOMIG 5 MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P Q:12 /30Days |
ZOMIG 5MG NASAL SPRAY |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P Q:6 /30Days |
ZOMIG ZMT 2.5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P Q:12 /30Days |
ZOMIG ZMT 5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | P Q:12 /30Days |
ZONALON 5% CREAM |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZONEGRAN 100MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZONEGRAN 25MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZONISAMIDE 100MG CAPSULE (100 CT) |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zonisamide 25mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZONISAMIDE 50MG CAPSULE (100 CT) |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
Zorbtive 8.8mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
5 |
Specialty Tier Drugs |
28% | N/A | P |
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
5 |
Specialty Tier Drugs |
28% | N/A | P |
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
5 |
Specialty Tier Drugs |
28% | N/A | P |
ZORTRESS TABLETS |
6 |
Injectable Drugs |
28% | N/A | P |
ZOSTAVAX VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
ZOSYN 2/0.25GM PRE-MIX BAG |
6 |
Injectable Drugs |
28% | N/A | None |
Zosyn 3.0; 0.375g/15mL; g/15mL 10 VIAL, SINGLE-USE in 1 CARTON / 3.375 mL in 1 VIAL, SINGLE-USE |
6 |
Injectable Drugs |
28% | N/A | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
6 |
Injectable Drugs |
28% | N/A | None |
ZOVIA 1/35-28 TABLET |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOVIA 1/50-28 TABLET |
1 |
Preferred Generic Drugs |
$7.50 | $22.50 | None |
ZOVIRAX 5% CREAM |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZOVIRAX 50mg/g |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZYBAN 150MG TABLET SA |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZYFLO 600 MG FILMTAB (120 TABLETS) |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZYFLO CR 600 MG TABLET |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZYLET 0.3%-0.5% SUSPENSION DROPS(FINAL DOSAGE FORM)(ML) |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZYMAR 3mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand Drugs |
$85.00 | $255.00 | None |
ZYPREXA 10MG VIAL |
6 |
Injectable Drugs |
28% | N/A | None |
Zytiga 250mg/1 120 TABLET in 1 BOTTLE |
5 |
Specialty Tier Drugs |
28% | N/A | P |
ZYVOX 100MG/5ML SUSPENSION |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYVOX 600MG TABLET |
3 |
Preferred Brand Drugs |
$40.00 | $120.00 | None |
ZYVOX 600MG/300ML IV SOLUTION |
6 |
Injectable Drugs |
28% | N/A | None |