2021 Medicare Part D Plan Formulary Information |
Network PlatinumPremier Pharmacy (PPO) (H5215-005-0)
Benefit Details
|
The Network PlatinumPremier Pharmacy (PPO) (H5215-005-0) Formulary Drugs Starting with the Letter Z in Portage County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $297.00 Deductible: $260 |
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 |
ZAFEMY 150-35 MCG/DAY PATCH [Xulane] |
2* |
Generic |
$8.00 | $20.00 | None |
ZAFIRLUKAST 10MG TABLETS |
2* |
Generic |
$8.00 | $20.00 | None |
ZAFIRLUKAST 20 MG TABLET [Accolate] |
2* |
Generic |
$8.00 | $20.00 | None |
ZALEPLON 10 MG CAPSULE [Sonata] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ZALEPLON 5 MG CAPSULE [Sonata] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ZARAH TABLET |
2* |
Generic |
$8.00 | $20.00 | None |
ZARONTIN 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S |
ZARONTIN 250 MG/5 ML SOLUTION |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S |
ZARXIO 300 MCG/0.5 ML SYRINGE |
5 |
Specialty Tier |
28% | N/A | None |
ZARXIO 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
28% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZAVESCA 100 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ZEBUTAL 50-325-40 MG CAPSULE |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:360 /30Days |
ZEJULA 100 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P Q:90 /30Days |
ZELAPAR 1.25MG ODT TABLET |
5 |
Specialty Tier |
28% | N/A | None |
ZELBORAF 240 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:240 /30Days |
ZEMAIRA 1000MG VIAL |
5 |
Specialty Tier |
28% | N/A | None |
ZEMBRACE SYMTOUCH 3 MG/0.5 ML PEN INJECTOR |
5 |
Specialty Tier |
28% | N/A | S |
ZEMDRI 500 MG/10 ML VIAL |
5 |
Specialty Tier |
28% | N/A | None |
ZEMPLAR 1 MCG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZEMPLAR 2 MCG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENATANE 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENATANE 20 MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZENATANE 30 MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZENATANE 40 MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZENPEP DR 10,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENPEP DR 15,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENPEP DR 20,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENPEP DR 25,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENPEP DR 3,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENPEP DR 40,000 UNIT CAPSULE DR |
5 |
Specialty Tier |
28% | N/A | None |
ZENPEP DR 5,000 UNIT CAPSULE DR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENZEDI 10 MG TABLET |
2* |
Generic |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZENZEDI 15 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENZEDI 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENZEDI 20 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENZEDI 30 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZENZEDI 5 MG TABLET |
2* |
Generic |
$8.00 | $20.00 | None |
ZENZEDI 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZEPATIER 50-100 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ZEPOSIA 0.23-0.46 MG START PCK CAP DS PK |
5 |
Specialty Tier |
28% | N/A | Q:7 /30Days |
ZEPOSIA 0.23-0.46-0.92 MG KIT CAP DS PK |
5 |
Specialty Tier |
28% | N/A | Q:37 /30Days |
ZEPOSIA 0.92 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | Q:30 /30Days |
ZERBAXA 1-0.5 GRAM VIAL |
5 |
Specialty Tier |
28% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZERVIATE 0.24% EYE DROP DROPERETTE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTORETIC 10-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTORETIC 20-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTORETIC 20-25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTRIL 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTRIL 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTRIL 20 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTRIL 30 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTRIL 40 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZESTRIL 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZETIA 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZETONNA 37 MCG NASAL SPRAY HFA AER AD |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:6 /30Days |
ZIAC 10-6.25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIAC 2.5-6.25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIAC 5-6.25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIAGEN 20mg/mL 240 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIAGEN 300mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIANA 1.2-0.025% GEL TOPICAL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ZIDOVUDINE 100MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZIDOVUDINE 10MG/ML SYRUP |
2* |
Generic |
$8.00 | $20.00 | None |
Zidovudine 300mg/1 12 BOTTLE CASE / 60 TABLET BOTTLE |
2* |
Generic |
$8.00 | $20.00 | None |
ZIEXTENZO 6 MG/0.6 ML SYRINGE |
5 |
Specialty Tier |
28% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZILEUTON ER 600 MG TABLET TBMP 12HR [Zyflo CR] |
5 |
Specialty Tier |
28% | N/A | None |
ZILXI 1.5% FOAM |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIOPTAN 0.0015% EYE DROPS |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S |
ZIPRASIDONE 20 MG/ML VIAL [Geodon] |
2* |
Generic |
$8.00 | $20.00 | None |
ZIPRASIDONE HCL 20 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | $20.00 | None |
ZIPRASIDONE HCL 40 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | $20.00 | None |
ZIPRASIDONE HCL 60 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | $20.00 | None |
ZIPRASIDONE HCL 80 MG CAPSULE [Geodon] |
2* |
Generic |
$8.00 | $20.00 | None |
ZIPSOR 25 MG CAPSULE 120 |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX 1g/1 3 POWDER, FOR SUSPENSION in 1 BOX |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZITHROMAX 200 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX 250 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX 250MG Z-PAK TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX 500MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX IV 500MG VIAL 10 VIAL BOX |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX ORAL SUSP 100MG/5ML |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZITHROMAX TRI-PAK 500MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOCOR 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOCOR 20 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOCOR 40 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOCOR 80 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOLINZA 100MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ZOLMITRIPTAN 2.5 MG ODT TABLET RAPDIS [Zomig -ZMT] |
2* |
Generic |
$8.00 | $20.00 | Q:9 /30Days |
ZOLMITRIPTAN 2.5 MG TABLET [Zomig] |
2* |
Generic |
$8.00 | $20.00 | Q:9 /30Days |
ZOLMITRIPTAN 5 MG ODT [Zomig, Zomig-ZMT] |
2* |
Generic |
$8.00 | $20.00 | Q:9 /30Days |
ZOLMITRIPTAN 5 MG TABLET [Zomig] |
2* |
Generic |
$8.00 | $20.00 | Q:9 /30Days |
ZOLOFT 100 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOLOFT 20 MG/ML ORAL CONC |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOLOFT 25MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOLOFT 50 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOLPIDEM TART ER 12.5 MG TABLET MPHASE [Ambien CR] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ZOLPIDEM TART ER 6.25 MG TABLET MPHASE [Ambien CR] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zolpidem Tartrate 1.75 mg tablet sl [Ambien, Edluar, Zolpimist] |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:20 /30Days |
ZOLPIDEM TARTRATE 10 MG TABLET [Ambien] |
2* |
Generic |
$8.00 | $20.00 | None |
Zolpidem Tartrate 3.5 mg tablet sl [Ambien, Edluar, Zolpimist] |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:20 /30Days |
ZOLPIDEM TARTRATE 5 MG TABLET [Ambien] |
2* |
Generic |
$8.00 | $20.00 | None |
ZOLPIMIST 5 MG ORAL SPRAY SPRAY/PUMP |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOMACTON 10 MG VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ZOMACTON 5 MG VIAL |
3* |
Preferred Brand |
$42.00 | $105.00 | P |
ZOMIG 2.5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:18 /28Days |
ZOMIG 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:9 /30Days |
ZOMIG 5 MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:18 /28Days |
ZOMIG 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZOMIG ZMT 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:9 /30Days |
ZOMIG ZMT 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:9 /30Days |
ZONALON 5% CREAM (g) |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ZONEGRAN 100 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ZONEGRAN 25 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ZONISAMIDE 100 MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZONISAMIDE 25 MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZONISAMIDE 50 MG CAPSULE |
2* |
Generic |
$8.00 | $20.00 | None |
ZONTIVITY 2.08 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Zorbtive 8.8mg/mL 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Specialty Tier |
28% | N/A | P |
ZORTRESS 0.25MG TABLETS |
5 |
Specialty Tier |
28% | 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 |
28% | N/A | P |
Zortress 0.75mg/1 60 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
28% | N/A | P |
ZORTRESS 1 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ZORVOLEX 18 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZORVOLEX 35 MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOSYN 2/0.25GM PRE-MIX BAG |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOSYN 3/0.375GRAM 24 BAGS PKG |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOVIA 1-35E TABLET |
2* |
Generic |
$8.00 | $20.00 | None |
ZOVIRAX 200 MG/5 ML Oral Suspension |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZOVIRAX 5% CREAM |
5 |
Specialty Tier |
28% | N/A | Q:5 /30Days |
ZOVIRAX 5% OINTMENT |
5 |
Specialty Tier |
28% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZTLIDO 1.8% TOPICAL SYSTEM Patch |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ZUBSOLV 0.7-0.18 MG SUBLIGUAL TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
ZUBSOLV 1.4-0.36 MG TABLET SL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:90 /30Days |
ZUBSOLV 11.4-2.9 MG TABLET SL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
ZUBSOLV 2.9-0.71 MG TABLET SL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
ZUBSOLV 5.7-1.4 MG TABLET SL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:90 /30Days |
ZUBSOLV 8.6-2.1 MG TABLET SL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:60 /30Days |
ZUPLENZ 4 MG SOLUBLE FILM |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ZUPLENZ 8 MG SOLUBLE FILM |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ZYCLARA 2.5% CREAM PUMP |
5 |
Specialty Tier |
28% | N/A | None |
ZYCLARA 3.75% CREAM PUMP |
5 |
Specialty Tier |
28% | 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 |
28% | N/A | P Q:60 /30Days |
ZYDELIG 150 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
ZYFLO 600 MG FILMTAB (120 TABLETS) |
5 |
Specialty Tier |
28% | N/A | None |
ZYKADIA 150 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:150 /30Days |
ZYLET EYE DROPS |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZYLOPRIM 100 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZYLOPRIM 300 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZYMAXID 5mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZYPITAMAG 2 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
ZYPITAMAG 4 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
ZYPREXA 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ZYPREXA 10MG VIAL |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ZYPREXA 15 MG TABLET |
5 |
Specialty Tier |
28% | N/A | S Q:30 /30Days |
ZYPREXA 2.5MG 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:30 /30Days |
ZYPREXA 20MG TABLET |
5 |
Specialty Tier |
28% | N/A | S Q:30 /30Days |
ZYPREXA 5MG TABLET (30 BOT) |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:30 /30Days |
ZYPREXA 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:30 /30Days |
ZYPREXA Relprevv 1 KIT in 1 CARTON |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ZYPREXA ZYDIS 10MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:30 /30Days |
ZYPREXA ZYDIS 15MG TABLET |
5 |
Specialty Tier |
28% | N/A | S Q:30 /30Days |
ZYPREXA ZYDIS 20MG TABLET |
5 |
Specialty Tier |
28% | N/A | S Q:30 /30Days |
ZYPREXA ZYDIS 5MG TABLET (30 BLPK) |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Zytiga 250mg/1 120 TABLET BOTTLE |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
ZYTIGA 500 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
ZYVOX 100MG/5ML SUSPENSION |
5 |
Specialty Tier |
28% | N/A | None |
ZYVOX 600 MG TABLET |
5 |
Specialty Tier |
28% | N/A | Q:60 /30Days |
ZYVOX 600 MG/300 ML-D5W PIGGYBACK |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |