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2014 Medicare Part D Plan Formulary Information
Humana Walmart Rx Plan (PDP) (S5884-168-0) Benefit Details
The Humana Walmart Rx Plan (PDP) (S5884-168-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 22 which includes: TX Plan Monthly Premium: $12.60 Deductible: $310 Qualifies for LIS: No
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
ZAFIRLUKAST 10MG TABLETS	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZAFIRLUKAST 20MG TABLETS	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZALEPLON 10MG CAPSULE	2*	Non-Preferred Generic	$4.00	$0.00	Q:90 /365Days
ZALEPLON 5MG CAPSULE	2*	Non-Preferred Generic	$4.00	$0.00	Q:90 /365Days
ZALTRAP 100 MG/4 ML VIAL	5	Specialty Tier	25%	N/A	P Q:40 /28Days
ZANOSAR 1GM VIAL	4	Non-Preferred Brand	39%	39%	None
ZAVESCA 100MG CAPSULE	5	Specialty Tier	25%	N/A	Q:90 /30Days
ZAZOLE 0.4% CREAM WITH APPLICATOR	2*	Non-Preferred Generic	$4.00	$0.00	None
ZAZOLE 0.8% CREAM WITH APPLICATOR	2*	Non-Preferred Generic	$4.00	$0.00	None
ZELBORAF 240mg/1 1 BOTTLE, PLASTIC per CARTON / 120 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	25%	N/A	P Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZEMAIRA 1000MG VIAL	5	Specialty Tier	25%	N/A	P
ZEMPLAR 1 MCG CAPSULE	3	Preferred Brand	20%	20%	P
ZEMPLAR 2 MCG CAPSULE	3	Preferred Brand	20%	20%	P
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE	3	Preferred Brand	20%	20%	P
ZEMPLAR 4 MCG CAPSULE	5	Specialty Tier	25%	N/A	P
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE	3	Preferred Brand	20%	20%	P
ZENCHENT FE TABLET CHEWABLE	4	Non-Preferred Brand	39%	39%	None
ZENPEP 109000; 20000; 68000 DELAYED RELEASE 100 CAPSULE BOTTLE	3	Preferred Brand	20%	20%	None
ZENPEP 27000; 5000; 17000 DELAYED RELEASE 100 CAPSULE BOTTLE	3	Preferred Brand	20%	20%	None
ZENPEP 55000; 10000; 34000 DELAYED RELEASE 100 CAPSULE BOTTLE	3	Preferred Brand	20%	20%	None
ZENPEP 82000; 15000; 51000 DELAYED RELEASE 100 CAPSULE BOTTLE	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZENPEP DR 25,000 UNITS CAPSULE	3	Preferred Brand	20%	20%	None
ZENPEP DR 3,000 UNITS CAPSULE	3	Preferred Brand	20%	20%	None
ZENZEDI 10 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:180 /30Days
ZENZEDI 15 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:120 /30Days
ZENZEDI 2.5 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:90 /30Days
ZENZEDI 20 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:90 /30Days
ZENZEDI 30 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZENZEDI 5 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:150 /30Days
ZENZEDI 7.5 MG TABLET	4	Non-Preferred Brand	39%	39%	Q:90 /30Days
ZERIT 15MG CAPSULE	4	Non-Preferred Brand	39%	39%	Q:120 /30Days
ZERIT 1MG/ML SOLUTION	4	Non-Preferred Brand	39%	39%	Q:2400 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZERIT 30MG CAPSULE	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZETIA 10MG TABLET (90 CT)	3	Preferred Brand	20%	20%	Q:30 /30Days
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE	4	Non-Preferred Brand	39%	39%	Q:960 /30Days
ZIDOVUDINE 100MG CAPSULE	3	Preferred Brand	20%	20%	Q:180 /30Days
ZIDOVUDINE 10MG/ML SYRUP	3	Preferred Brand	20%	20%	Q:1680 /28Days
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE	3	Preferred Brand	20%	20%	Q:60 /30Days
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon]	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon]	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon]	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon]	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR	4	Non-Preferred Brand	39%	39%	Q:5 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Zoledronic Acid 4 mg/5 ml vial	5	Specialty Tier	25%	N/A	P Q:15 /21Days
zoledronic acid 5 mg/100 ml	4	Non-Preferred Brand	39%	39%	P Q:100 /365Days
ZOLINZA 100MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:120 /30Days
ZOLPIDEM TARTRATE 10MG TABLETS	2*	Non-Preferred Generic	$4.00	$0.00	Q:90 /365Days
Zolpidem Tartrate 5mg/1 100 FILM COATED TABLETS in BOTTLE	2*	Non-Preferred Generic	$4.00	$0.00	Q:90 /365Days
ZONISAMIDE 100MG CAPSULE (100 CT)	2*	Non-Preferred Generic	$4.00	$0.00	None
Zonisamide 25mg 100 CAPSULE BOTTLE	2*	Non-Preferred Generic	$4.00	$0.00	None
ZONISAMIDE 50MG CAPSULE (100 CT)	2*	Non-Preferred Generic	$4.00	$0.00	None
ZONTIVITY 2.08 MG TABLET	4	Non-Preferred Brand	39%	39%	P Q:30 /30Days
ZORTRESS 0.25MG TABLETS	4	Non-Preferred Brand	39%	39%	P Q:60 /30Days
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK	4	Non-Preferred Brand	39%	39%	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK	4	Non-Preferred Brand	39%	39%	P Q:60 /30Days
ZOSTAVAX VIAL	4	Non-Preferred Brand	39%	39%	Q:1 /365Days
ZOVIA 1/35-28 TABLET	4	Non-Preferred Brand	39%	39%	None
ZOVIA 1/50-28 TABLET	4	Non-Preferred Brand	39%	39%	None
ZOVIRAX 5% CREAM	4	Non-Preferred Brand	39%	39%	S
ZOVIRAX 5% OINTMENT	4	Non-Preferred Brand	39%	39%	P
ZYBAN 150MG TABLET SA	3	Preferred Brand	20%	20%	Q:90 /30Days
ZYKADIA 150 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:150 /30Days
ZYMAXID 5mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER	4	Non-Preferred Brand	39%	39%	Q:3 /25Days
ZYPREXA 10MG VIAL	4	Non-Preferred Brand	39%	39%	Q:60 /30Days
Zytiga 250mg/1 120 TABLET BOTTLE	5	Specialty Tier	25%	N/A	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZYVOX 100MG/5ML SUSPENSION	5	Specialty Tier	25%	N/A	None
ZYVOX 600MG TABLET	5	Specialty Tier	25%	N/A	None
ZYVOX 600MG/300ML IV SOLUTION	5	Specialty Tier	25%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Humana Walmart Rx Plan (PDP) 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 $310 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 September 2014 )

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.