Q1Medicare.com 2015 Medicare Part D or Medicare Advantage Plan Formulary Browser

2015 Medicare Part D Plan Formulary Information
Symphonix Premier Rx (PDP) (S0522-069-0) Benefit Details
The Symphonix Premier Rx (PDP) (S0522-069-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 22 which includes: TX Plan Monthly Premium: $92.20 Deductible: $0 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	3	Preferred Brand	$30.00	$90.00	Q:60 /30Days
ZAFIRLUKAST 20MG TABLETS	3	Preferred Brand	$30.00	$90.00	Q:60 /30Days
ZALEPLON 10MG CAPSULE	2	Non-Preferred Generic	$4.00	$12.00	Q:90 /365Days
ZALEPLON 5MG CAPSULE	2	Non-Preferred Generic	$4.00	$12.00	Q:90 /365Days
ZALTRAP 100 MG/4 ML VIAL	5	Specialty Tier	33%	N/A	P
Zamicet 10-325 mg/15 ml soln	3	Preferred Brand	$30.00	$90.00	Q:5400 /30Days
ZANOSAR 1 GM VIAL	4	Non-Preferred Brand	$70.00	$210.00	None
ZAVESCA 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P
ZAZOLE 0.4% CREAM WITH APPLICATOR	3	Preferred Brand	$30.00	$90.00	None
ZAZOLE 0.8% CREAM WITH APPLICATOR	3	Preferred Brand	$30.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZELAPAR 1.25MG ODT TABLET	4	Non-Preferred Brand	$70.00	$210.00	S
ZELBORAF 240mg/1 1 BOTTLE, PLASTIC per CARTON / 120 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	33%	N/A	P
ZEMAIRA 1000MG VIAL	5	Specialty Tier	33%	N/A	P
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Non-Preferred Generic	$4.00	$12.00	None
ZENCHENT FE TABLET CHEWABLE	3	Preferred Brand	$30.00	$90.00	None
ZENPEP DR 10,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
ZENPEP DR 15,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
ZENPEP DR 20,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
ZENPEP DR 25,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
ZENPEP DR 3,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
ZENPEP DR 40,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZENPEP DR 5,000 UNITS CAPSULE	3	Preferred Brand	$30.00	$90.00	None
ZETIA 10MG TABLET (90 CT)	3	Preferred Brand	$30.00	$90.00	Q:30 /30Days
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE	3	Preferred Brand	$30.00	$90.00	None
ZIDOVUDINE 100MG CAPSULE	4	Non-Preferred Brand	$70.00	$210.00	None
ZIDOVUDINE 10MG/ML SYRUP	3	Preferred Brand	$30.00	$90.00	None
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE	3	Preferred Brand	$30.00	$90.00	None
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon]	4	Non-Preferred Brand	$70.00	$210.00	None
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon]	4	Non-Preferred Brand	$70.00	$210.00	None
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon]	4	Non-Preferred Brand	$70.00	$210.00	None
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon]	4	Non-Preferred Brand	$70.00	$210.00	None
ZIPSOR 25 MG CAPSULE	4	Non-Preferred Brand	$70.00	$210.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR	4	Non-Preferred Brand	$70.00	$210.00	None
ZMAX 2g/60mL 60 mL in 1 BOTTLE	4	Non-Preferred Brand	$70.00	$210.00	None
Zoledronic Acid 4 mg/5 ml vial	4	Non-Preferred Brand	$70.00	$210.00	P
zoledronic acid 5 mg/100 ml	4	Non-Preferred Brand	$70.00	$210.00	None
ZOLINZA 100MG CAPSULE	5	Specialty Tier	33%	N/A	P
ZOLMITRIPTAN 2.5 MG ODT [Zomig, Zomig-ZMT]	4	Non-Preferred Brand	$70.00	$210.00	Q:9 /30Days
ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT]	4	Non-Preferred Brand	$70.00	$210.00	Q:9 /30Days
ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT]	4	Non-Preferred Brand	$70.00	$210.00	Q:9 /30Days
ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT]	4	Non-Preferred Brand	$70.00	$210.00	Q:9 /30Days
ZOLPIDEM TARTRATE 10MG TABLETS [Ambien, Edluar, Zolpimist]	1	Preferred Generic	$2.00	$6.00	Q:90 /365Days
ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist]	1	Preferred Generic	$2.00	$6.00	Q:90 /365Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZOLPIDEM TARTRATE ER 12.5 MG TAB [Ambien, Edluar, Zolpimist]	3	Preferred Brand	$30.00	$90.00	Q:90 /365Days
ZOLPIDEM TARTRATE ER 6.25MG TABLETS [Ambien, Edluar, Zolpimist]	3	Preferred Brand	$30.00	$90.00	Q:90 /365Days
ZOMACTON 10 MG VIAL	5	Specialty Tier	33%	N/A	P
ZOMACTON 5 MG VIAL	5	Specialty Tier	33%	N/A	P
ZONISAMIDE 100MG CAPSULE (100 CT)	3	Preferred Brand	$30.00	$90.00	None
Zonisamide 25mg 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$4.00	$12.00	None
ZONISAMIDE 50MG CAPSULE (100 CT)	2	Non-Preferred Generic	$4.00	$12.00	None
ZORTRESS 0.25MG TABLETS	4	Non-Preferred Brand	$70.00	$210.00	P Q:60 /30Days
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK	5	Specialty Tier	33%	N/A	P
ZOSTAVAX VIAL	3	Preferred Brand	$30.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZOSYN 2/0.25GM PRE-MIX BAG	3	Preferred Brand	$30.00	$90.00	None
ZOSYN 3/0.375GRAM 24 BAGS PKG	3	Preferred Brand	$30.00	$90.00	None
ZOVIA 1/35-28 TABLET	3	Preferred Brand	$30.00	$90.00	None
ZOVIA 1/50-28 TABLET	2	Non-Preferred Generic	$4.00	$12.00	None
ZUBSOLV 1.4-0.36 MG TABLET SL	3	Preferred Brand	$30.00	$90.00	Q:90 /30Days
ZUBSOLV 5.7-1.4 MG TABLET SL	3	Preferred Brand	$30.00	$90.00	Q:90 /30Days
ZUBSOLV 8.6-2.1 MG TABLET SL	3	Preferred Brand	$30.00	$90.00	Q:60 /30Days
ZYCLARA 2.5% CREAM PUMP	3	Preferred Brand	$30.00	$90.00	None
ZYCLARA 3.75% CREAM	5	Specialty Tier	33%	N/A	None
ZYDELIG 100 MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
ZYDELIG 150 MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZYFLO 600 MG FILMTAB (120 TABLETS)	5	Specialty Tier	33%	N/A	S Q:120 /30Days
ZYFLO CR 600 MG TABLET	5	Specialty Tier	33%	N/A	S Q:120 /30Days
ZYKADIA 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:150 /30Days
ZYLET 0.3%-0.5% SUSPENSION DROPS(FINAL DOSAGE FORM)(ML)	4	Non-Preferred Brand	$70.00	$210.00	None
ZYPREXA Relprevv 1 KIT in 1 CARTON	5	Specialty Tier	33%	N/A	None
Zytiga 250mg/1 120 TABLET BOTTLE	5	Specialty Tier	33%	N/A	P
ZYVOX 100MG/5ML SUSPENSION	5	Specialty Tier	33%	N/A	P
ZYVOX 600mg/1 30 FILM COATED TABLETS in BOTTLE, UNIT-DOSE	5	Specialty Tier	33%	N/A	P
ZYVOX 600MG/300ML IV SOLUTION	5	Specialty Tier	33%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Symphonix Premier Rx (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 $320 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.