2015 Medicare Part D Plan Formulary Information |
BlueMedicare HMO LifeTime (HMO) (H1026-040-0)
Benefit Details
|
The BlueMedicare HMO LifeTime (HMO) (H1026-040-0) Formulary Drugs Starting with the Letter Z in BREVARD County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 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 |
$5.00 | $15.00 | None |
ZAFIRLUKAST 20MG TABLETS |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZALEPLON 10MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:90 /365Days |
ZALEPLON 5MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:90 /365Days |
ZALTRAP 100 MG/4 ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ZANAFLEX 4 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZANOSAR 1 GM VIAL |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZANTAC 150 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZANTAC 300 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZARONTIN 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZAVESCA 100 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ZAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZAZOLE 0.8% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Zebeta 10mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZEBETA 5MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZELBORAF 240mg/1 1 BOTTLE, PLASTIC per CARTON / 120 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days |
ZEMPLAR 1 MCG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZEMPLAR 2 MCG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENATANE 10 MG CAPSULE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENATANE 20 MG CAPSULE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZENATANE 40 MG CAPSULE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZENCHENT FE TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZENPEP DR 10,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENPEP DR 15,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENPEP DR 20,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENPEP DR 25,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENPEP DR 3,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENPEP DR 40,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ZENPEP DR 5,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENZEDI 10 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:180 /30Days |
ZENZEDI 5 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:90 /30Days |
ZERIT 15MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
ZERIT 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:2400 /30Days |
ZERIT 20MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
ZERIT 30MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
ZERIT 40MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
ZESTORETIC 10-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTORETIC 20-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTORETIC 20-25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTRIL 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZESTRIL 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTRIL 20 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTRIL 30 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTRIL 40 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZESTRIL 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZETIA 10MG TABLET (90 CT) |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ZIAC 10-6.25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZIAC 5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:960 /30Days |
ZIAGEN 300mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZIDOVUDINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:180 /30Days |
ZIDOVUDINE 10MG/ML SYRUP |
1 |
Preferred Generic |
$2.00 | $6.00 | Q:1920 /30Days |
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:60 /30Days |
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:60 /30Days |
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:60 /30Days |
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:60 /30Days |
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon] |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:60 /30Days |
ZITHROMAX 250MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZITHROMAX 500MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZITHROMAX 600MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZITHROMAX ORAL SUSP 200MG/5ML |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZOCOR 10MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:45 /30Days |
ZOCOR 20MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
ZOCOR 40MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:45 /30Days |
ZOCOR 80MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZOCOR TABLETS 5 MG |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:45 /30Days |
ZOFRAN 4mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P |
ZOFRAN 4MG/5ML ORAL TUBEX |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOFRAN 8 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P |
ZOFRAN ODT 4MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P |
ZOFRAN ODT 8mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P |
ZOHYDRO ER 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
ZOHYDRO ER 15 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
ZOHYDRO ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
ZOHYDRO ER 30 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
ZOHYDRO ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
ZOHYDRO ER 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
Zoledronic Acid 4 mg/5 ml vial |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
zoledronic acid 5 mg/100 ml |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOLINZA 100MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
Zoloft 100mg/1 100 FILM COATED TABLETS in DOSE PACK |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days |
ZOLOFT 20MG/ML ORAL CONC |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:300 /30Days |
ZOLOFT 25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Zoloft 50mg/1 100 FILM COATED TABLETS in DOSE PACK |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZOLPIDEM TARTRATE 10MG TABLETS [Ambien, Edluar, Zolpimist] |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:90 /365Days |
ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist] |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:90 /365Days |
Zometa 4mg/100mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
ZONALON 5% CREAM |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZONEGRAN 100MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZONEGRAN 25MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZONISAMIDE 100MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Zonisamide 25mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZONISAMIDE 50MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ZONTIVITY 2.08 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZORTRESS 0.25MG TABLETS |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P |
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | P |
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | P |
ZOSTAVAX VIAL |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:1 /999Days |
ZOSYN 2/0.25GM PRE-MIX BAG |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
Zosyn 3.0; 0.375g/15mL; g/15mL 10 VIAL, SINGLE-USE per CARTON / 3.375 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | 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 |
$5.00 | $15.00 | None |
ZOVIRAX 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZOVIRAX 200 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZOVIRAX 5% OINTMENT |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZYBAN 150mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZYDELIG 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
ZYDELIG 150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
ZYKADIA 150 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:150 /30Days |
ZYLOPRIM 100MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZYLOPRIM 300 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ZYPREXA 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA 10MG VIAL |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:90 /30Days |
ZYPREXA 15 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA 2.5mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA 20MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA 5MG TABLET (30 BOT) |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA Relprevv 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | Q:2 /28Days |
ZYPREXA ZYDIS 10MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA ZYDIS 15MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA ZYDIS 20MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK) |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | 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% | P |
ZYVOX 600mg/1 30 FILM COATED TABLETS in BOTTLE, UNIT-DOSE |
5 |
Specialty Tier |
33% | 33% | P |
ZYVOX 600MG/300ML IV SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |