2018 Medicare Part D Plan Formulary Information |
Network PlatinumSelect (PPO) (H5215-008-0)
Benefit Details
|
The Network PlatinumSelect (PPO) (H5215-008-0) Formulary Drugs Starting with the Letter Z in Green Lake County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $0.00 Deductible: $395 |
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* |
Generic |
$8.00 | N/A | None |
ZAFIRLUKAST 20MG TABLETS |
2* |
Generic |
$8.00 | N/A | None |
ZALEPLON 10 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | S |
ZALEPLON 5 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | S |
ZALTRAP 100 MG/4 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ZANAFLEX 2 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZANAFLEX 4 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZANAFLEX 4 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZANAFLEX 6 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZANOSAR 1 GM VIAL |
3 |
Preferred Brand |
$42.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZANTAC 1,000 MG/40 ML VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZANTAC 300 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZARAH TABLET |
2* |
Generic |
$8.00 | N/A | None |
ZARONTIN 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
ZARONTIN 250 MG/5ML SYRUP |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
ZARXIO 300 MCG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | None |
ZARXIO 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | None |
ZAVESCA 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ZEBUTAL 50-325-40 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | Q:360 /30Days |
ZEGERID 20MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZEGERID 20MG PACKET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZEGERID 40MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZEGERID 40MG PACKET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZEJULA 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
ZELAPAR 1.25MG ODT TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZELBORAF 240 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ZEMAIRA 1000MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ZEMBRACE SYMTOUCH 3 MG/0.5 ML |
5 |
Specialty Tier |
25% | N/A | S |
ZEMPLAR 1 MCG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZEMPLAR 2 MCG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENATANE 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENATANE 20 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
ZENATANE 30 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
ZENATANE 40 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$8.00 | N/A | None |
ZENPEP DR 10,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENPEP DR 15,000 UNITS CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENPEP DR 20,000 UNIT CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENPEP DR 25,000 UNIT CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENPEP DR 25,000 UNITS CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENPEP DR 3,000 UNITS CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENPEP DR 40,000 UNIT CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ZENPEP DR 5,000 UNIT CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENPEP DR 5,000 UNITS CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENZEDI 10 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
ZENZEDI 15 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENZEDI 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENZEDI 20 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENZEDI 30 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZENZEDI 5 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
ZENZEDI 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZEPATIER 50-100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZERBAXA 1-0.5 GRAM VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ZERIT 15MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZERIT 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZERIT 20MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZERIT 30MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZERIT 40MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTORETIC 10-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTORETIC 20-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTORETIC 20-25 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTRIL 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTRIL 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZESTRIL 20 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTRIL 30 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTRIL 40 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZESTRIL 5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZETIA 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZETONNA 37 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:12 /30Days |
ZIAC 10-6.25 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZIAC 5-6.25 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZIAGEN 300mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZIANA 1.2-0.025% GEL TOPICAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZIDOVUDINE 100MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
ZIDOVUDINE 10MG/ML SYRUP |
2* |
Generic |
$8.00 | N/A | None |
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE |
2* |
Generic |
$8.00 | N/A | None |
ZILEUTON ER 600 MG TABLET TBMP 12HR [Zyflo CR] |
5 |
Specialty Tier |
25% | N/A | None |
ZINECARD 250 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ZINPLAVA 1,000 MG/40 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ZIOPTAN 0.0015% EYE DROPS |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | N/A | None |
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | N/A | None |
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | N/A | None |
ZIPSOR 25 MG CAP 120 |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX 1g/1 3 POWDER, FOR SUSPENSION in 1 BOX |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX 200 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX 250MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX 500MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX 600MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOCOR 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOCOR 20 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOCOR 40 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOCOR 80 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOCOR TABLETS 5 MG |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOFRAN 4 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZOFRAN 4MG/5ML ORAL TUBEX |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZOFRAN 8 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZOFRAN ODT 4 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZOFRAN ODT 8 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOHYDRO ER 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZOHYDRO ER 15 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZOHYDRO ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZOHYDRO ER 30 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZOHYDRO ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZOHYDRO ER 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZOLEDRONIC ACID 4 MG/5 ML VIAL [Zometa] |
2* |
Generic |
$8.00 | N/A | P |
ZOLEDRONIC ACID 5 MG/100 ML [Zometa] |
2* |
Generic |
$8.00 | N/A | None |
ZOLINZA 100MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ZOLMITRIPTAN 2.5 MG ODT [Zomig, Zomig-ZMT] |
2* |
Generic |
$8.00 | N/A | Q:9 /30Days |
ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT] |
2* |
Generic |
$8.00 | N/A | Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT] |
2* |
Generic |
$8.00 | N/A | Q:9 /30Days |
ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT] |
2* |
Generic |
$8.00 | N/A | Q:9 /30Days |
ZOLOFT 100 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOLOFT 25MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOLOFT 50 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Zolpidem Tartrate 1.75 mg tab sl [Ambien, Edluar, Zolpimist] |
3 |
Preferred Brand |
$42.00 | N/A | P Q:20 /30Days |
ZOLPIDEM TARTRATE 10 MG TABLET [Ambien, Edluar, Zolpimist] |
3 |
Preferred Brand |
$42.00 | N/A | S |
Zolpidem Tartrate 3.5 mg tablet sl [Ambien, Edluar, Zolpimist] |
3 |
Preferred Brand |
$42.00 | N/A | P Q:20 /30Days |
ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist] |
3 |
Preferred Brand |
$42.00 | N/A | S |
ZOLPIDEM TARTRATE ER 12.5 MG TAB [Ambien, Edluar, Zolpimist] |
3 |
Preferred Brand |
$42.00 | N/A | S |
ZOLPIDEM TARTRATE ER 6.25MG TABLETS [Ambien, Edluar, Zolpimist] |
3 |
Preferred Brand |
$42.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOMACTON 10 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ZOMACTON 5 MG VIAL |
3 |
Preferred Brand |
$42.00 | N/A | P |
Zometa 4mg/100mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE |
5 |
Specialty Tier |
25% | N/A | P |
ZOMETA 4MG/5ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ZOMIG 2.5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:18 /28Days |
ZOMIG 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:9 /30Days |
ZOMIG 5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:18 /28Days |
ZOMIG 5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:9 /30Days |
ZOMIG ZMT 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:9 /30Days |
ZOMIG ZMT 5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:9 /30Days |
ZONEGRAN 100 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZONEGRAN 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZONISAMIDE 100 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | P |
ZONISAMIDE 25 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | P |
ZONISAMIDE 50 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | P |
ZONTIVITY 2.08 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Zorbtive 8.8mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
25% | N/A | P |
ZORTRESS 0.25MG TABLETS |
5 |
Specialty Tier |
25% | N/A | P |
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P |
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P |
ZORVOLEX 18 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZORVOLEX 35 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOSTAVAX VIAL |
3 |
Preferred Brand |
$42.00 | N/A | None |
ZOSYN 2/0.25GM PRE-MIX BAG |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOSYN 3.375 GRAM VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOVIA 1-35E TABLET |
2* |
Generic |
$8.00 | N/A | None |
ZOVIRAX 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOVIRAX 200 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZOVIRAX 5% CREAM |
5 |
Specialty Tier |
25% | N/A | None |
ZOVIRAX 5% OINTMENT |
5 |
Specialty Tier |
25% | N/A | None |
ZOVIRAX 800 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZUBSOLV 1.4-0.36 MG TABLET SL |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZUBSOLV 11.4-2.9 MG TABLET SL |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
ZUBSOLV 2.9-0.71 MG TABLET SL |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
ZUBSOLV 5.7-1.4 MG TABLET SL |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
ZUBSOLV 8.6-2.1 MG TABLET SL |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:60 /30Days |
ZUPLENZ 4 MG SOLUBLE FILM |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZUPLENZ 8 MG SOLUBLE FILM |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
ZURAMPIC 200 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYBAN 150mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYCLARA 2.5% CREAM PUMP |
5 |
Specialty Tier |
25% | N/A | None |
ZYCLARA 3.75% CREAM PUMP |
5 |
Specialty Tier |
25% | N/A | None |
ZYDELIG 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYDELIG 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ZYFLO 600 MG FILMTAB (120 TABLETS) |
5 |
Specialty Tier |
25% | N/A | None |
ZYFLO CR 600 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ZYKADIA 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
ZYLET EYE DROPS |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYLOPRIM 100MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYLOPRIM 300 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYMAXID 5mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYPITAMAG 1 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
ZYPITAMAG 2 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
ZYPITAMAG 4 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | S |
ZYPREXA 10MG VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ZYPREXA 15 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
ZYPREXA 2.5MG 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
ZYPREXA 20MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
ZYPREXA 5MG TABLET (30 BOT) |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
ZYPREXA 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
ZYPREXA Relprevv 1 KIT in 1 CARTON |
3 |
Preferred Brand |
$42.00 | N/A | None |
ZYPREXA ZYDIS 10MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | S |
ZYPREXA ZYDIS 15MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
ZYPREXA ZYDIS 20MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK) |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
Zytiga 250mg/1 120 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | None |
ZYTIGA 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ZYVOX 100MG/5ML SUSPENSION |
5 |
Specialty Tier |
25% | N/A | None |
ZYVOX 600 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ZYVOX 600MG/300ML IV SOLUTION |
5 |
Specialty Tier |
25% | N/A | None |