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First Health Part D Value Plus (PDP) (S5768-155-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2825)
Tier 5 (720)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-155-0)
Benefit Details           
The First Health Part D Value Plus (PDP) (S5768-155-0)
Formulary Drugs Starting with the Letter Z
in CMS PDP Region 32 which includes: CA
Plan Monthly Premium: $56.30 Deductible: $0 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 50%50%Q:60
/30Days
ZAFIRLUKAST 20MG TABLETS   4 Non-Preferred Drug 50%50%Q:60
/30Days
ZALEPLON 10 MG CAPSULE   3 Preferred Brand $47.00$141.00P Q:60
/30Days
ZALEPLON 5 MG CAPSULE   3 Preferred Brand $47.00$141.00P Q:30
/30Days
ZALTRAP 100 MG/4 ML VIAL   5 Specialty Tier 33%N/AP
ZANAFLEX 2 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ZANAFLEX 4 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ZANAFLEX 4 MG TABLET   4 Non-Preferred Drug 50%50%None
ZANAFLEX 6 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ZANOSAR 1 GM VIAL   4 Non-Preferred Drug 50%50%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 50%50%None
ZANTAC 300 MG TABLET   4 Non-Preferred Drug 50%50%None
ZARAH TABLET   3 Preferred Brand $47.00$141.00None
ZARONTIN 250 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ZARONTIN 250 MG/5ML SYRUP   4 Non-Preferred Drug 50%50%None
ZAVESCA 100 MG CAPSULE   5 Specialty Tier 33%N/AP
ZEBUTAL 50-325-40 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ZEGERID 20MG CAPSULE   5 Specialty Tier 33%N/AS Q:30
/30Days
ZEGERID 20MG PACKET   5 Specialty Tier 33%N/AS Q:30
/30Days
ZEGERID 40MG CAPSULE   5 Specialty Tier 33%N/AS Q:30
/30Days
ZEGERID 40MG PACKET   5 Specialty Tier 33%N/AS 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 33%N/AP Q:90
/30Days
ZELAPAR 1.25MG ODT TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ZELBORAF 240 MG TABLET   5 Specialty Tier 33%N/AP
ZEMAIRA 1000MG VIAL   5 Specialty Tier 33%N/AP
ZEMBRACE SYMTOUCH 3 MG/0.5 ML   4 Non-Preferred Drug 50%50%S Q:8
/30Days
ZEMPLAR 1 MCG CAPSULE   4 Non-Preferred Drug 50%50%None
ZEMPLAR 2 MCG CAPSULE   4 Non-Preferred Drug 50%50%None
Zemplar 2ug/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%None
Zemplar 5ug/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 2 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Drug 50%50%None
ZENATANE 10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ZENATANE 20 MG CAPSULE   4 Non-Preferred Drug 50%50%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 50%50%None
ZENATANE 40 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $47.00$141.00None
ZENPEP DR 10,000 UNIT CAPSULE DR   4 Non-Preferred Drug 50%50%None
ZENPEP DR 15,000 UNITS CAPSULE   4 Non-Preferred Drug 50%50%None
ZENPEP DR 20,000 UNIT CAPSULE   4 Non-Preferred Drug 50%50%None
ZENPEP DR 25,000 UNIT CAPSULE   4 Non-Preferred Drug 50%50%None
ZENPEP DR 25,000 UNITS CAPSULE   4 Non-Preferred Drug 50%50%None
ZENPEP DR 3,000 UNITS CAPSULE   4 Non-Preferred Drug 50%50%None
ZENPEP DR 40,000 UNIT CAPSULE   4 Non-Preferred Drug 50%50%None
ZENPEP DR 5,000 UNIT CAPSULE   4 Non-Preferred Drug 50%50%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 50%50%None
ZENZEDI 10 MG TABLET   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ZENZEDI 15 MG TABLET   4 Non-Preferred Drug 50%50%P Q:120
/30Days
ZENZEDI 2.5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ZENZEDI 20 MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
ZENZEDI 30 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
ZENZEDI 5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ZENZEDI 7.5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:240
/30Days
ZERIT 1MG/ML SOLUTION   4 Non-Preferred Drug 50%50%None
ZESTORETIC 10-12.5 MG TABLET   4 Non-Preferred Drug 50%50%None
ZESTORETIC 20-12.5 MG TABLET   4 Non-Preferred Drug 50%50%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 50%50%None
ZESTRIL 10 MG TABLET   4 Non-Preferred Drug 50%50%None
ZESTRIL 2.5 MG TABLET   4 Non-Preferred Drug 50%50%None
ZESTRIL 20 MG TABLET   4 Non-Preferred Drug 50%50%None
ZESTRIL 30 MG TABLET   4 Non-Preferred Drug 50%50%None
ZESTRIL 40 MG TABLET   4 Non-Preferred Drug 50%50%None
ZESTRIL 5 MG TABLET   4 Non-Preferred Drug 50%50%None
ZETIA 10 MG TABLET   3 Preferred Brand $47.00$141.00None
ZIAC 10-6.25 MG TABLET   4 Non-Preferred Drug 50%50%None
ZIAC 2.5-6.25MG TABLET   4 Non-Preferred Drug 50%50%None
ZIAC 5-6.25 MG TABLET   4 Non-Preferred Drug 50%50%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 $47.00$141.00None
ZIDOVUDINE 100MG CAPSULE   3 Preferred Brand $47.00$141.00None
ZIDOVUDINE 10MG/ML SYRUP   3 Preferred Brand $47.00$141.00None
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE   3 Preferred Brand $47.00$141.00None
ZIOPTAN 0.0015% EYE DROPS   4 Non-Preferred Drug 50%50%S
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon]   3 Preferred Brand $47.00$141.00Q:60
/30Days
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon]   3 Preferred Brand $47.00$141.00Q:60
/30Days
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon]   3 Preferred Brand $47.00$141.00Q:60
/30Days
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon]   3 Preferred Brand $47.00$141.00Q:60
/30Days
ZIPSOR 25 MG CAP 120   4 Non-Preferred Drug 50%50%S
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR   4 Non-Preferred Drug 50%50%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 50%50%None
ZITHROMAX 200 MG/5 ML SUSP   4 Non-Preferred Drug 50%50%None
ZITHROMAX 250MG TABLET   4 Non-Preferred Drug 50%50%None
ZITHROMAX 250MG Z-PAK TABLET   4 Non-Preferred Drug 50%50%None
ZITHROMAX 500MG TABLET   4 Non-Preferred Drug 50%50%None
ZITHROMAX 600MG TABLET   4 Non-Preferred Drug 50%50%None
ZITHROMAX IV 500MG VIAL 10 VIAL BOX   4 Non-Preferred Drug 50%50%None
ZITHROMAX ORAL SUSP 100MG/5ML   4 Non-Preferred Drug 50%50%None
ZITHROMAX TRI-PAK 500MG TABLET   4 Non-Preferred Drug 50%50%None
ZOCOR 10 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ZOCOR 20 MG TABLET   4 Non-Preferred Drug 50%50%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 50%50%Q:30
/30Days
ZOCOR 80 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ZOCOR TABLETS 5 MG   4 Non-Preferred Drug 50%50%Q:30
/30Days
ZOFRAN 4 MG TABLET   4 Non-Preferred Drug 50%50%P
ZOFRAN 4MG/5ML ORAL TUBEX   4 Non-Preferred Drug 50%50%P Q:900
/30Days
ZOFRAN 8 MG TABLET   4 Non-Preferred Drug 50%50%P
ZOFRAN ODT 4 MG TABLET   4 Non-Preferred Drug 50%50%P
ZOFRAN ODT 8 MG TABLET   4 Non-Preferred Drug 50%50%P
ZOLEDRONIC ACID 4 MG/5 ML VIAL [Zometa]   4 Non-Preferred Drug 50%50%None
ZOLEDRONIC ACID 5 MG/100 ML [Zometa]   4 Non-Preferred Drug 50%50%None
ZOLINZA 100MG CAPSULE   5 Specialty Tier 33%N/AP
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]   4 Non-Preferred Drug 50%50%Q:6
/30Days
ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT]   4 Non-Preferred Drug 50%50%Q:6
/30Days
ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT]   4 Non-Preferred Drug 50%50%Q:6
/30Days
ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT]   4 Non-Preferred Drug 50%50%Q:6
/30Days
ZOLOFT 100 MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ZOLOFT 25MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZOLOFT 50 MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
Zolpidem Tartrate 1.75 mg tab sl [Ambien, Edluar, Zolpimist]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ZOLPIDEM TARTRATE 10 MG TABLET [Ambien, Edluar, Zolpimist]   2 Generic $2.00$6.00P Q:30
/30Days
Zolpidem Tartrate 3.5 mg tablet sl [Ambien, Edluar, Zolpimist]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist]   2 Generic $2.00$6.00P 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 50%50%S Q:12
/30Days
ZOMIG 2.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:6
/30Days
ZOMIG 5 MG NASAL SPRAY   4 Non-Preferred Drug 50%50%S Q:12
/30Days
ZOMIG 5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:6
/30Days
ZONEGRAN 100 MG CAPSULE   4 Non-Preferred Drug 50%50%S
ZONEGRAN 25 MG CAPSULE   4 Non-Preferred Drug 50%50%S
ZONISAMIDE 100 MG CAPSULE   3 Preferred Brand $47.00$141.00None
ZONISAMIDE 25 MG CAPSULE   3 Preferred Brand $47.00$141.00None
ZONISAMIDE 50 MG CAPSULE   3 Preferred Brand $47.00$141.00None
ZONTIVITY 2.08 MG TABLET   4 Non-Preferred Drug 50%50%None
ZORTRESS 0.25MG TABLETS   3 Preferred Brand $47.00$141.00P
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 33%N/AP
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP
ZOSTAVAX VIAL   3 Preferred Brand $47.00$141.00Q:1
/999Days
ZOVIA 1-35E TABLET   3 Preferred Brand $47.00$141.00None
ZOVIRAX 200 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ZOVIRAX 200 MG/5 ML SUSP   4 Non-Preferred Drug 50%50%None
ZOVIRAX 5% CREAM   4 Non-Preferred Drug 50%50%None
ZOVIRAX 5% OINTMENT   4 Non-Preferred Drug 50%50%None
ZYBAN 150mg/1 60 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ZYCLARA 2.5% CREAM PUMP   4 Non-Preferred Drug 50%50%None
ZYCLARA 3.75% CREAM PUMP   4 Non-Preferred Drug 50%50%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 33%N/AP
ZYDELIG 150 MG TABLET   5 Specialty Tier 33%N/AP
ZYKADIA 150 MG CAPSULE   5 Specialty Tier 33%N/AP
ZYLET EYE DROPS   3 Preferred Brand $47.00$141.00None
ZYLOPRIM 100MG TABLET   4 Non-Preferred Drug 50%50%None
ZYLOPRIM 300 MG TABLET   4 Non-Preferred Drug 50%50%None
ZYMAXID 5mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER   4 Non-Preferred Drug 50%50%None
ZYPREXA 10 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA 10MG VIAL   4 Non-Preferred Drug 50%50%None
ZYPREXA 15 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA 2.5MG 30 TABLET BOTTLE   4 Non-Preferred Drug 50%50%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 50%50%S Q:30
/30Days
ZYPREXA 5MG TABLET (30 BOT)   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA 7.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA Relprevv 1 KIT in 1 CARTON   4 Non-Preferred Drug 50%50%P Q:2
/28Days
ZYPREXA ZYDIS 10MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA ZYDIS 15MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA ZYDIS 20MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ZYPREXA ZYDIS 5MG TABLET (30 BLPK)   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Zytiga 250mg/1 120 TABLET BOTTLE   5 Specialty Tier 33%N/AP
ZYTIGA 500 MG TABLET   5 Specialty Tier 33%N/AP
ZYVOX 100MG/5ML SUSPENSION   5 Specialty Tier 33%N/AP 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 33%N/AP Q:56
/28Days
ZYVOX 600MG/300ML IV SOLUTION   5 Specialty Tier 33%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Value Plus (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2018 )

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.