Q1Medicare.com 2018 Medicare Part D or Medicare Advantage Plan Formulary Browser

2018 Medicare Part D Plan Formulary Information
Anthem Blue Cross MedicareRx Gold (PDP) (S5596-035-0) Benefit Details
The Anthem Blue Cross MedicareRx Gold (PDP) (S5596-035-0) Formulary Drugs Starting with the Letter Z in CMS PDP Region 32 which includes: CA Plan Monthly Premium: $169.80 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	$28.00	N/A	None
ZAFIRLUKAST 20MG TABLETS	3	Preferred Brand	$28.00	N/A	None
ZALEPLON 10 MG CAPSULE	3	Preferred Brand	$28.00	N/A	P Q:60 /30Days
ZALEPLON 5 MG CAPSULE	3	Preferred Brand	$28.00	N/A	P Q:30 /30Days
ZALTRAP 100 MG/4 ML VIAL	5	Specialty Tier	33%	N/A	P
ZANOSAR 1 GM VIAL	4	Non-Preferred Drug	35%	N/A	P
ZARAH TABLET	4	Non-Preferred Drug	35%	N/A	None
ZARONTIN 250 MG CAPSULE	3	Preferred Brand	$28.00	N/A	None
ZAVESCA 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P
ZEJULA 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZELBORAF 240 MG TABLET	5	Specialty Tier	33%	N/A	P Q:240 /30Days
Zenchent 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	3	Preferred Brand	$28.00	N/A	None
ZENPEP DR 10,000 UNIT CAPSULE DR	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 15,000 UNITS CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 20,000 UNIT CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 25,000 UNIT CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 25,000 UNITS CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 3,000 UNITS CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 40,000 UNIT CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 5,000 UNIT CAPSULE	4	Non-Preferred Drug	35%	N/A	None
ZENPEP DR 5,000 UNITS CAPSULE	4	Non-Preferred Drug	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZERIT 1MG/ML SOLUTION	4	Non-Preferred Drug	35%	N/A	Q:2400 /30Days
ZESTORETIC 10-12.5 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZESTORETIC 20-12.5 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZESTORETIC 20-25 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZESTRIL 10 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZESTRIL 20 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZESTRIL 40 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZESTRIL 5 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZIAC 10-6.25 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZIAC 5-6.25 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE	4	Non-Preferred Drug	35%	N/A	Q:960 /30Days
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 Drug	35%	N/A	P
ZIDOVUDINE 100MG CAPSULE	3	Preferred Brand	$28.00	N/A	Q:180 /30Days
ZIDOVUDINE 10MG/ML SYRUP	3	Preferred Brand	$28.00	N/A	Q:1920 /30Days
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE	2	Generic	$3.00	N/A	Q:60 /30Days
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon]	3	Preferred Brand	$28.00	N/A	Q:240 /30Days
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon]	3	Preferred Brand	$28.00	N/A	Q:120 /30Days
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon]	3	Preferred Brand	$28.00	N/A	Q:60 /30Days
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon]	3	Preferred Brand	$28.00	N/A	Q:60 /30Days
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR	4	Non-Preferred Drug	35%	N/A	None
ZITHROMAX 1g/1 3 POWDER, FOR SUSPENSION in 1 BOX	3	Preferred Brand	$28.00	N/A	None
ZITHROMAX 250MG TABLET	3	Preferred Brand	$28.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZITHROMAX 250MG Z-PAK TABLET	3	Preferred Brand	$28.00	N/A	None
ZOCOR 10 MG TABLET	3	Preferred Brand	$28.00	N/A	None
ZOCOR TABLETS 5 MG	3	Preferred Brand	$28.00	N/A	None
ZOLEDRONIC ACID 4 MG/5 ML VIAL [Zometa]	4	Non-Preferred Drug	35%	N/A	P
ZOLEDRONIC ACID 5 MG/100 ML [Zometa]	4	Non-Preferred Drug	35%	N/A	P
ZOLINZA 100MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:120 /30Days
ZOLMITRIPTAN 2.5 MG TABLET [Zomig, Zomig-ZMT]	4	Non-Preferred Drug	35%	N/A	Q:9 /30Days
ZOLMITRIPTAN 5 MG TABLET [Zomig, Zomig-ZMT]	4	Non-Preferred Drug	35%	N/A	Q:9 /30Days
ZOLPIDEM TARTRATE 10 MG TABLET [Ambien, Edluar, Zolpimist]	2	Generic	$3.00	N/A	P Q:30 /30Days
ZOLPIDEM TARTRATE 5mg/1 100 FILM COATED TABLETS in BOTTLE [Ambien, Edluar, Zolpimist]	2	Generic	$3.00	N/A	P Q:30 /30Days
Zometa 4mg/100mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ZONISAMIDE 100 MG CAPSULE	2	Generic	$3.00	N/A	None
ZONISAMIDE 25 MG CAPSULE	2	Generic	$3.00	N/A	None
ZONISAMIDE 50 MG CAPSULE	2	Generic	$3.00	N/A	None
ZORTRESS 0.25MG TABLETS	4	Non-Preferred Drug	35%	N/A	P
Zortress 0.5mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK	5	Specialty Tier	33%	N/A	P
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK	5	Specialty Tier	33%	N/A	P
ZOSTAVAX VIAL	4	Non-Preferred Drug	35%	N/A	None
ZOVIA 1-35E TABLET	3	Preferred Brand	$28.00	N/A	None
ZOVIRAX 5% CREAM	4	Non-Preferred Drug	35%	N/A	Q:5 /30Days
ZOVIRAX 800 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
ZYDELIG 100 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
ZYDELIG 150 MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
ZYKADIA 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:150 /30Days
ZYLET EYE DROPS	4	Non-Preferred Drug	35%	N/A	None
ZYPREXA Relprevv 1 KIT in 1 CARTON	4	Non-Preferred Drug	35%	N/A	Q:2 /28Days
Zytiga 250mg/1 120 TABLET BOTTLE	5	Specialty Tier	33%	N/A	P Q:120 /30Days
ZYTIGA 500 MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Anthem Blue Cross MedicareRx Gold (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.