2009 Medicare Part D Plan Formulary Information |
RMHP Basic Rx (S5860-001-0)
Benefit Details
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The RMHP Basic Rx (S5860-001-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 27 which includes: CO
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Drugs Starting with Letter O
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
2 |
Preferred brand drugs |
$39.00 | $78.00 | P |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
2 |
Preferred brand drugs |
$39.00 | $78.00 | P |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
2 |
Preferred brand drugs |
$39.00 | $78.00 | P |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
2 |
Preferred brand drugs |
$39.00 | $78.00 | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OCUFEN 0.03% EYE DROPS |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | Q:3 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUFLOX 0.3% EYE DROPS |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | Q:10 /30Days |
OCUSULF-10 EYE DROPS |
1 |
Generic drugs |
$8.75 | $17.50 | Q:30 /30Days |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Generic drugs |
$8.75 | $17.50 | Q:8 /30Days |
OFLOXACIN 0.3% DROPS |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OFLOXACIN 200MG TABLET (50 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OFLOXACIN 300MG TABLET (50 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OFLOXACIN 400MG TABLET (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Generic drugs |
$8.75 | $17.50 | Q:10 /30Days |
OGEN 0.625MG TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OGEN 1.5MG TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OGEN 2.5MG TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OGESTREL TABLET 0.05MG/0.5MG |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OLUX 0.05% FOAM |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OLUX-E 0.05% FOAM |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OMEPRAZOLE 20MG CAPSULE DELAYED RELEASE |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OMNICEF 125MG/5ML SUSP |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OMNICEF 300MG CAPSULE |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OMNICEF 300MG OMNI-PAC CAP |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OMNICEF SUS 250/5ML |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
2 |
Preferred brand drugs |
$39.00 | $78.00 | P |
ONCASPAR 750UNIT/ML VIAL |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 24MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | P |
ONDANSETRON HCL 4MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | P |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
1 |
Generic drugs |
$8.75 | $17.50 | P |
ONDANSETRON HCL 8MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | P |
ONDANSETRON INJECTION 2MG 5X2ML VIAL |
1 |
Generic drugs |
$8.75 | $17.50 | None |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | P |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | P |
ONTAK INJECTION 300MCG/2ML VIALSU |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ONXOL PACLITAXEL INJECTION 6 MG/ML |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OPANA 10MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA 5MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA ER 10MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA ER 15MG TABLET SR 12HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA ER 20MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA ER 30MG TABLET SR 12HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA ER 40MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA ER 5MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPANA ER 7.5MG TABLET SR 12HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OPTIPRANOLOL 0.3% EYE DROPS |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | Q:10 /30Days |
OPTIVAR 0.05% DROPS |
2 |
Preferred brand drugs |
$39.00 | $78.00 | Q:6 /30Days |
ORACEA 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAMORPH SR 100MG TABLET SA |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORAMORPH SR 15MG TABLET SA |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORAMORPH SR 30MG TABLET SA |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORAMORPH SR 60MG TABLET SA |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORAP 1MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAP 2MG TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORAPRED 15MG/5ML SOLUTION ORAL |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORAPRED ODT 10MG TABLET RAPID DISSOLVE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAPRED ODT 15MG TABLET RAPID DISSOLVE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORAPRED ODT 30MG TABLET RAPID DISSOLVE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORENCIA 250MG VIAL |
4 |
Specialty drugs |
33% | 33% | P |
ORFADIN 10MG CAPSULE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORFADIN 2MG CAPSULE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORFADIN 5MG CAPSULE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORPHENADRINE CITRATE ASPIRIN AND CAFFEINE TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
ORPHENADRINE CITRATE ER TABLET 100MG (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
ORPHENADRINE CITRATE INJECTION 3030MG/ML 10ML VIAL |
1 |
Generic drugs |
$8.75 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORPHENADRINE COMP FORTE TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
ORPHENADRINE COMPOUND 25-385-30 TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
ORTHO EVRA DIS WEEK .75MG / 6MG |
2 |
Preferred brand drugs |
$39.00 | $78.00 | Q:3 /28Days |
ORTHO MICRON TABLET DIALPAK |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORTHO TRI-CYCLEN LO TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORTHO-CEPT 28 DAY TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORTHO-CYCLEN TABLET 0.25/35 |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORTHO-EST 0.625 TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
ORTHO-EST 1.25 TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
ORTHO-NOVUM 1/50-28 TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
ORTHO-NOVUM 7/7/7-28 TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORTHOCLONE OKT-3 5MG/5ML |
2 |
Preferred brand drugs |
$39.00 | $78.00 | P |
OSMOPREP TABLET 1.5GM |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OTICIN HC 3.5-10K-1 SUSPENSION DROPS |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OVCON-35 28 TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OVCON-50 28 TABLET |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OVIDE 0.5% LOTION |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXACILLIN 1GM/50ML INJ |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXACILLIN 2GM/50ML INJ |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXACILLIN FOR INJECTION 1 GM |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXACILLIN FOR INJECTION 2 GM/VIAL |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXACILLIN INJECTION |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN SODIUM FOR INJECTION 1 GM/VIAL |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXANDRIN 10MG TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OXANDRIN 2.5MG TABLET |
3 |
Non-preferred brand drugs |
$59.00 | $118.00 | None |
OXANDROLONE 10MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXANDROLONE 2.5MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXAPROZIN 600MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXCARBAZEPINE 150MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXISTAT 1% CREAM 30GM TUBE |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXISTAT 1% LOTION |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXSORALEN 1% LOTION |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXSORALEN-ULTRA 10MG CAP |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYBUTYNIN 5MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE HCL 15MG TABLET (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE HCL 5MG TABLET (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE HCL TABLET 30MG (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT) |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE HCL-IBUPROFEN 400MG-5MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCODONE/ASA 4.88/325 TABLET |
1 |
Generic drugs |
$8.75 | $17.50 | None |
OXYCONTIN 10MG TABLET SA |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYCONTIN 15MG TABLET SR 12HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYCONTIN 20MG TABLET SA |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYCONTIN 30MG TABLET SR 12HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYCONTIN 40MG TABLET SA |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYCONTIN 60MG TABLET SR 12HR |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
OXYCONTIN 80MG TABLET SA |
2 |
Preferred brand drugs |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYTROL 3.9MG/24HR PATCH |
2 |
Preferred brand drugs |
$39.00 | $78.00 | Q:8 /28Days |