2014 Medicare Part D Plan Formulary Information |
Kaiser Permanente Senior Advantage Enhanced Stanis (HMO) (H0524-040-0)
Benefit Details
|
The Kaiser Permanente Senior Advantage Enhanced Stanis (HMO) (H0524-040-0) Formulary Drugs Starting with the Letter Z in STANISLAUS County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $75.00 Deductible: $0 |
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 10MG TABLETS |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZAFIRLUKAST 20MG TABLETS |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZALEPLON 10MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZALEPLON 5MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZALTRAP 100 MG/4 ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ZAMICET SOLN 325MG; 10MG/15ML |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZANAFLEX 2MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZANAFLEX 4MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZANAFLEX 4MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZANAFLEX 6MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZANOSAR 1GM VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZANTAC 150MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZANTAC 15MG/ML SYRUP |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZANTAC 25 MG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZANTAC 300MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZARONTIN 250MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZARONTIN 250MG/5ML SYRUP |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZAVESCA 100MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
ZAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZAZOLE 0.8% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Zebeta 10mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZEBETA 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZEGERID 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZEGERID 20MG PACKET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZEGERID 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZEGERID 40MG PACKET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZELAPAR 1.25MG ODT TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZELBORAF 240mg/1 1 BOTTLE, PLASTIC per CARTON / 120 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | 25% | None |
ZEMAIRA 1000MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ZEMPLAR 1 MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ZEMPLAR 2 MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZEMPLAR 4 MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENCHENT FE TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENPEP 109000; 20000; 68000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZENPEP 27000; 5000; 17000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZENPEP 55000; 10000; 34000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZENPEP 82000; 15000; 51000 DELAYED RELEASE 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZENPEP DR 25,000 UNITS CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZENPEP DR 3,000 UNITS CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZENZEDI 10 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENZEDI 15 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENZEDI 2.5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENZEDI 20 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENZEDI 30 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENZEDI 5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZENZEDI 7.5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZERIT 15MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZERIT 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZERIT 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZERIT 30MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZERIT 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZESTORETIC 12.5; 20mg/1; mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTORETIC 12.5/10MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTORETIC 25/20MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTRIL 10mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTRIL 2.5mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTRIL 30MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTRIL 5mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTRIL TABLETS 20MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZESTRIL TABLETS 40 MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZETIA 10MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZETONNA 37 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | 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 |
$95.00 | $190.00 | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZIAC 5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZIAGEN 300mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZIANA 1.2-0.025% GEL TOPICAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZIDOVUDINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZIDOVUDINE 10MG/ML SYRUP |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZINACEF 1.5 GM ADD-VANT VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZINACEF 7.5 GM VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZINACEF 750 MG ADD-VANT VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZINECARD 250 MG VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZIOPTAN 0.0015% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZIPSOR 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX 1g/1 3 POWDER, FOR SUSPENSION in 1 BOX |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZITHROMAX 250MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX 600MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX ORAL SUSP 200MG/5ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZMAX 2g/60mL 60 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOCOR 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOCOR 20MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOCOR 40MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOCOR 80MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOCOR TABLETS 5 MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOFRAN 2MG/ML MDV VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOFRAN 4mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ZOFRAN 4MG/5ML ORAL TUBEX |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ZOFRAN 8 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ZOFRAN ODT 4MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ZOFRAN ODT 8mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ZOHYDRO ER 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOHYDRO ER 15 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOHYDRO ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOHYDRO ER 30 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOHYDRO ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOHYDRO ER 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Zoledronic Acid 4 mg/5 ml vial |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
zoledronic acid 5 mg/100 ml |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLINZA 100MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
ZOLMITRIPTAN 2.5 MG ODT [Zomig, Zomig-ZMT] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLOFT 100MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOLOFT 20MG/ML ORAL CONC |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOLOFT 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOLOFT 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOLPIDEM TART ER 12.5 MG TAB |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLPIDEM TARTRATE 10MG TABLETS |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Zolpidem Tartrate 5mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOLPIDEM TARTRATE 6.25MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Zolpimist 5mg/1 1 CONTAINER per CARTON / 60 SPRAY, METERED in 1 CONTAINER |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Zometa 4mg/100mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOMETA 4MG/5ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOMIG 2.5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOMIG 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOMIG 5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOMIG 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOMIG ZMT 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOMIG ZMT 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZONALON 5% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZONEGRAN 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZONEGRAN 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZONISAMIDE 100MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Zonisamide 25mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZONISAMIDE 50MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZONTIVITY 2.08 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Zorbtive 8.8mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
25% | 25% | None |
ZORTRESS 0.25MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | 25% | P |
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | 25% | P |
ZORVOLEX 18 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZORVOLEX 35 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOSTAVAX VIAL |
6 |
Vaccines |
$0.00 | N/A | None |
ZOSYN 2/0.25GM PRE-MIX BAG |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Zosyn 3.0; 0.375g/15mL; g/15mL 10 VIAL, SINGLE-USE per CARTON / 3.375 mL in 1 VIAL, SINGLE-USE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOVIA 1/35-28 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOVIA 1/50-28 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
ZOVIRAX 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOVIRAX 200MG/5ML ORAL SUSP |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOVIRAX 400MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOVIRAX 5% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZOVIRAX 5% OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZUBSOLV 1.4-0.36 MG TABLET SL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZUBSOLV 5.7-1.4 MG TABLET SL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYBAN 150MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYCLARA 2.5% CREAM PUMP |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYCLARA 3.75% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYFLO 600 MG FILMTAB (120 TABLETS) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYFLO CR 600 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
ZYKADIA 150 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
ZYLET 0.3%-0.5% SUSPENSION DROPS(FINAL DOSAGE FORM)(ML) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYLOPRIM 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYLOPRIM 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYMAXID 5mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ZYPREXA 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA 10MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA 15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zyprexa 2.5mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA 5MG TABLET (30 BOT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA ZYDIS 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA ZYDIS 15MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA ZYDIS 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Zytiga 250mg/1 120 TABLET BOTTLE |
5 |
Specialty Tier |
25% | 25% | None |
ZYVOX 100MG/5ML SUSPENSION |
5 |
Specialty Tier |
25% | 25% | None |
ZYVOX 600MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYVOX 600MG/300ML IV SOLUTION |
5 |
Specialty Tier |
25% | 25% | None |