2013 Medicare Part D Plan Formulary Information |
BlueMedicare HMO (HMO) (H1026-001-0)
Benefit Details
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The BlueMedicare HMO (HMO) (H1026-001-0) Formulary Drugs Starting with the Letter Z in MIAMI-DADE County, FL: CMS MA Region 9 which includes: FL
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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 |
$0.00 | $0.00 | S |
ZAFIRLUKAST TABLETS |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | S |
ZALEPLON 10MG CAPSULE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ZALEPLON 5MG CAPSULE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ZALTRAP 100 MG/4 ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ZANAFLEX 4MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZANOSAR 1GM VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ZANTAC 150MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZANTAC 15MG/ML SYRUP |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZANTAC 300MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZARONTIN 250MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZAVESCA 100MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ZAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
ZAZOLE 0.8% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
Zebeta 10mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZEBETA 5MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZELBORAF 240mg/1 1 BOTTLE, PLASTIC in 1 CARTON / 120 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days |
ZEMPLAR 1 MCG CAPSULE |
3 |
Preferred Brand |
$25.00 | $75.00 | P |
ZEMPLAR 2 MCG CAPSULE |
3 |
Preferred Brand |
$25.00 | $75.00 | P |
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Preferred Brand |
$25.00 | $75.00 | P |
ZEMPLAR 4 MCG CAPSULE |
3 |
Preferred Brand |
$25.00 | $75.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$25.00 | $75.00 | P |
ZENCHENT FE TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
ZENPEP 109000; 20000; 68000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$25.00 | $75.00 | None |
ZENPEP 27000; 5000; 17000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$25.00 | $75.00 | None |
ZENPEP 55000; 10000; 34000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$25.00 | $75.00 | None |
ZENPEP 82000; 15000; 51000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$25.00 | $75.00 | None |
ZENPEP DR 25,000 UNITS CAPSULE |
3 |
Preferred Brand |
$25.00 | $75.00 | None |
ZENPEP DR 3,000 UNITS CAPSULE |
3 |
Preferred Brand |
$25.00 | $75.00 | None |
ZEOSA 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
ZERIT 15MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:60 /30Days |
ZERIT 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:2400 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZERIT 20MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:60 /30Days |
ZERIT 30MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:60 /30Days |
ZERIT 40MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:60 /30Days |
ZESTORETIC 12.5; 20mg/1; mg/1 |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTORETIC TABLETS |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTORETIC TABLETS |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTRIL 10mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTRIL 2.5mg/1 |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTRIL 5mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTRIL TABLETS |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZESTRIL TABLETS 20MG 100 BOT |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZESTRIL TABLETS 40 MG |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZETIA 10MG TABLET (90 CT) |
3 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ZIAC 10-6.25MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZIAC 5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE |
3 |
Preferred Brand |
$25.00 | $75.00 | Q:960 /30Days |
ZIAGEN 300mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$25.00 | $75.00 | Q:60 /30Days |
ZIDOVUDINE 100MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days |
ZIDOVUDINE 10MG/ML SYRUP |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:1920 /30Days |
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
ZINACEF/DEXTROSE 750MG/50ML |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZINACEF/WATER 1.5GM/50ML |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZIPRASIDONE HCL 20 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
ZIPRASIDONE HCL 40 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
ZIPRASIDONE HCL 60 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
ZIPRASIDONE HCL 80 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
ZITHROMAX 250MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZITHROMAX 500MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZITHROMAX 600MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX ORAL SUSP 200MG/5ML |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOCOR 10MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:45 /30Days |
ZOCOR 20MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:60 /30Days |
ZOCOR 40MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:45 /30Days |
ZOCOR 80MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZOCOR TABLETS 5 MG |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:45 /30Days |
ZOFRAN 4mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P |
ZOFRAN 4MG/5ML ORAL TUBEX |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P |
ZOFRAN 8MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P |
ZOFRAN ODT 4MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOFRAN ODT 8mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P |
Zoledronic Acid 4 mg/5 ml vial |
5 |
Specialty Tier |
33% | 33% | None |
ZOLINZA 100MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
ZOLOFT 100MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | S Q:60 /30Days |
ZOLOFT 20MG/ML ORAL CONC |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | S Q:300 /30Days |
ZOLOFT 25MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | S Q:30 /30Days |
ZOLOFT 50MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | S Q:30 /30Days |
Zolpidem Tartrate 5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ZOLPIDEM TARTRATE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Zometa 4mg/100mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
ZOMETA 4MG/5ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZONALON 5% CREAM |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZONEGRAN 100MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZONEGRAN 25MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZONISAMIDE 100MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Zonisamide 25mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ZONISAMIDE 50MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | P |
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | P |
ZORTRESS TABLETS |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P |
ZOSTAVAX VIAL |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:1 /999Days |
ZOSYN 2/0.25GM PRE-MIX BAG |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zosyn 3.0; 0.375g/15mL; g/15mL 10 VIAL, SINGLE-USE in 1 CARTON / 3.375 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOVIA 1/35-28 TABLET |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None |
ZOVIRAX 200MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOVIRAX 200MG/5ML ORAL SUSP |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOVIRAX 400MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOVIRAX 5% OINTMENT |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZOVIRAX 800MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZYBAN 150MG TABLET SA |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZYLOPRIM 100MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
ZYLOPRIM 300 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA 10MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA 10MG VIAL |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:90 /30Days |
ZYPREXA 15MG TABLET (1000 BOT) |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
Zyprexa 2.5mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA 20MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA 5MG TABLET (30 BOT) |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA 7.5MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA ZYDIS 10MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA ZYDIS 15MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA ZYDIS 20MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK) |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zytiga 250mg/1 120 TABLET BOTTLE |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
ZYVOX 100MG/5ML SUSPENSION |
5 |
Specialty Tier |
33% | 33% | None |
ZYVOX 600MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
ZYVOX 600MG/300ML IV SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |