2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 Qualifies for LIS: No |
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  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
ZAFIRLUKAST 20MG TABLETS  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
ZALEPLON 10 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:60 /30Days |
ZALEPLON 5 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:30 /30Days |
ZALTRAP 100 MG/4 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
ZANAFLEX 2 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZANAFLEX 4 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZANAFLEX 4 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZANAFLEX 6 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZANOSAR 1 GM VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
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 Drug |
37% | N/A | None |
ZANTAC 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZARAH TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZARONTIN 250 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZARONTIN 250 MG/5ML SYRUP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZAVESCA 100 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
ZEBUTAL 50-325-40 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
ZEGERID 20MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
ZEGERID 20MG PACKET  |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
ZEGERID 40MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
ZEGERID 40MG PACKET  |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZEJULA 100 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ZELAPAR 1.25MG ODT TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
ZELBORAF 240 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
ZEMAIRA 1000MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
ZEMBRACE SYMTOUCH 3 MG/0.5 ML  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:8 /30Days |
ZEMPLAR 1 MCG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZEMPLAR 2 MCG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENATANE 10 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENATANE 20 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENATANE 30 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENATANE 40 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZENPEP DR 10,000 UNIT CAPSULE DR  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 15,000 UNITS CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 20,000 UNIT CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 25,000 UNIT CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 25,000 UNITS CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 3,000 UNITS CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 40,000 UNIT CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENPEP DR 5,000 UNIT CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENPEP DR 5,000 UNITS CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZENZEDI 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
ZENZEDI 15 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:120 /30Days |
ZENZEDI 2.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
ZENZEDI 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:90 /30Days |
ZENZEDI 30 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
ZENZEDI 5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
ZENZEDI 7.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:240 /30Days |
ZERIT 1MG/ML SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTORETIC 10-12.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTORETIC 20-12.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZESTORETIC 20-25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTRIL 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTRIL 2.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTRIL 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTRIL 30 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTRIL 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZESTRIL 5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZETIA 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZIAC 10-6.25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZIAC 2.5-6.25MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZIAC 5-6.25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZIDOVUDINE 100MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZIDOVUDINE 10MG/ML SYRUP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZIOPTAN 0.0015% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | S |
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon] ![Compare how all Medicare Part D PDP plans in LA cover ZIPRASIDONE HCL 20 MG CAPSULE [Geodon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon] ![Compare how all Medicare Part D PDP plans in LA cover ZIPRASIDONE HCL 40 MG CAPSULE [Geodon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon] ![Compare how all Medicare Part D PDP plans in LA cover ZIPRASIDONE HCL 60 MG CAPSULE [Geodon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon] ![Compare how all Medicare Part D PDP plans in LA cover ZIPRASIDONE HCL 80 MG CAPSULE [Geodon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
ZIPSOR 25 MG CAP 120  |
4 |
Non-Preferred Drug |
37% | N/A | S |
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX 1g/1 3 POWDER, FOR SUSPENSION in 1 BOX  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX 200 MG/5 ML SUSP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX 250MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX 250MG Z-PAK TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX 500MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX 600MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX ORAL SUSP 100MG/5ML  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZITHROMAX TRI-PAK 500MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZOCOR 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
ZOCOR 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOCOR 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
ZOCOR 80 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
ZOCOR TABLETS 5 MG  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
ZOFRAN 4 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
ZOFRAN 4MG/5ML ORAL TUBEX  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:900 /30Days |
ZOFRAN 8 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
ZOFRAN ODT 4 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
ZOFRAN ODT 8 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
ZOLEDRONIC ACID 4 MG/5 ML VIAL [Zometa] ![Compare how all Medicare Part D PDP plans in LA cover ZOLEDRONIC ACID 4 MG/5 ML VIAL [Zometa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZOLEDRONIC ACID 5 MG/100 ML [Zometa] ![Compare how all Medicare Part D PDP plans in LA cover ZOLEDRONIC ACID 5 MG/100 ML [Zometa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZOLINZA 100MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOLMITRIPTAN 2.5 MG ODT [Zomig, Zomig-ZMT] ![Compare how all Medicare Part D PDP plans in LA cover ZOLMITRIPTAN 2.5 MG ODT [Zomig, Zomig-ZMT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:6 /30Days |
ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT] ![Compare how all Medicare Part D PDP plans in LA cover ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:6 /30Days |
ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT] ![Compare how all Medicare Part D PDP plans in LA cover ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:6 /30Days |
ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT] ![Compare how all Medicare Part D PDP plans in LA cover ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:6 /30Days |
ZOLOFT 100 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
ZOLOFT 25MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZOLOFT 50 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
Zolpidem Tartrate 1.75 mg tab sl [Ambien, Edluar, Zolpimist] ![Compare how all Medicare Part D PDP plans in LA cover Zolpidem Tartrate 1.75 mg tab sl [Ambien, Edluar, Zolpimist].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
ZOLPIDEM TARTRATE 10 MG TABLET [Ambien, Edluar, Zolpimist] ![Compare how all Medicare Part D PDP plans in LA cover ZOLPIDEM TARTRATE 10 MG TABLET [Ambien, Edluar, Zolpimist].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | P Q:30 /30Days |
Zolpidem Tartrate 3.5 mg tablet sl [Ambien, Edluar, Zolpimist] ![Compare how all Medicare Part D PDP plans in LA cover Zolpidem Tartrate 3.5 mg tablet sl [Ambien, Edluar, Zolpimist].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist] ![Compare how all Medicare Part D PDP plans in LA cover ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOMIG 2.5 MG NASAL SPRAY  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:12 /30Days |
ZOMIG 2.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:6 /30Days |
ZOMIG 5 MG NASAL SPRAY  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:12 /30Days |
ZOMIG 5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:6 /30Days |
ZONEGRAN 100 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | S |
ZONEGRAN 25 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | S |
ZONISAMIDE 100 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZONISAMIDE 25 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZONISAMIDE 50 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZONTIVITY 2.08 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZORTRESS 0.25MG TABLETS  |
3 |
Preferred Brand |
$46.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
ZOSTAVAX VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | Q:1 /999Days |
ZOVIA 1-35E TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZOVIRAX 200 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZOVIRAX 200 MG/5 ML SUSP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZOVIRAX 5% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZOVIRAX 5% OINTMENT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZYBAN 150mg/1 60 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
ZYCLARA 2.5% CREAM PUMP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZYCLARA 3.75% CREAM PUMP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYDELIG 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
ZYDELIG 150 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
ZYKADIA 150 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
ZYLET EYE DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ZYLOPRIM 100MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZYLOPRIM 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZYMAXID 5mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZYPREXA 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA 10MG VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ZYPREXA 15 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA 2.5MG 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA 20MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA 5MG TABLET (30 BOT)  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA 7.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA Relprevv 1 KIT in 1 CARTON  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:2 /28Days |
ZYPREXA ZYDIS 10MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA ZYDIS 15MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA ZYDIS 20MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK)  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Zytiga 250mg/1 120 TABLET BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P |
ZYTIGA 500 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
ZYVOX 100MG/5ML SUSPENSION  |
5 |
Specialty Tier |
25% | N/A | P Q:1800 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYVOX 600 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
ZYVOX 600MG/300ML IV SOLUTION  |
5 |
Specialty Tier |
25% | N/A | P |