2009 Medicare Part D Plan Formulary Information |
Humana PDP Standard S5884-076 (S5884-076-0)
Benefit Details
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The Humana PDP Standard S5884-076 (S5884-076-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 18 which includes: MO
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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 |
OCELLA TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUFEN 0.03% EYE DROPS |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OCUFLOX 0.3% EYE DROPS |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OCUSULF-10 EYE DROPS |
1 |
Preferred Generic |
15% | 15% | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Preferred Generic |
15% | 15% | None |
OFLOXACIN 0.3% DROPS |
1 |
Preferred Generic |
15% | 15% | None |
OFLOXACIN 200MG TABLET (50 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OFLOXACIN 300MG TABLET (50 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OFLOXACIN 400MG TABLET (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
15% | 15% | None |
OGEN 0.625MG TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OGEN 1.5MG TABLET |
1 |
Preferred Generic |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OGEN 2.5MG TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OGESTREL TABLET 0.05MG/0.5MG |
1 |
Preferred Generic |
15% | 15% | None |
OLUX 0.05% FOAM |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OLUX-E 0.05% FOAM |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic |
15% | 15% | Q:30 /30Days |
OMEPRAZOLE 20MG CAPSULE DELAYED RELEASE |
1 |
Preferred Generic |
15% | 15% | Q:60 /30Days |
OMEPRAZOLE DR CAPSULE |
1 |
Preferred Generic |
15% | 15% | Q:30 /30Days |
OMNICEF 125MG/5ML SUSP |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OMNICEF 300MG CAPSULE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OMNICEF 300MG OMNI-PAC CAP |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OMNICEF SUS 250/5ML |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:8 /28Days |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:5 /30Days |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:5 /30Days |
ONCASPAR 750UNIT/ML VIAL |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ONDANSETRON HCL 24MG TABLET |
1 |
Preferred Generic |
15% | 15% | Q:4 /28Days |
ONDANSETRON HCL 4MG TABLET |
1 |
Preferred Generic |
15% | 15% | Q:30 /30Days |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
1 |
Preferred Generic |
15% | 15% | Q:450 /30Days |
ONDANSETRON HCL 8MG TABLET |
1 |
Preferred Generic |
15% | 15% | Q:45 /30Days |
ONDANSETRON INJECTION 2MG 5X2ML VIAL |
1 |
Preferred Generic |
15% | 15% | None |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Preferred Generic |
15% | 15% | Q:30 /30Days |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Preferred Generic |
15% | 15% | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONTAK INJECTION 300MCG/2ML VIALSU |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P |
ONXOL PACLITAXEL INJECTION 6 MG/ML |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OPANA ER 10MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPANA ER 15MG TABLET SR 12HR |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPANA ER 20MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPANA ER 30MG TABLET SR 12HR |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPANA ER 40MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPANA ER 5MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPANA ER 7.5MG TABLET SR 12HR |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OPTIPRANOLOL 0.3% EYE DROPS |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OPTIVAR 0.05% DROPS |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:120 /30Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:120 /30Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:120 /30Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:120 /30Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:120 /30Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:120 /30Days |
ORAMORPH SR 100MG TABLET SA |
1 |
Preferred Generic |
15% | 15% | None |
ORAMORPH SR 15MG TABLET SA |
1 |
Preferred Generic |
15% | 15% | None |
ORAMORPH SR 30MG TABLET SA |
1 |
Preferred Generic |
15% | 15% | None |
ORAMORPH SR 60MG TABLET SA |
1 |
Preferred Generic |
15% | 15% | None |
ORAP 1MG TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORAP 2MG TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORAPRED 15MG/5ML SOLUTION ORAL |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORAPRED ODT 10MG TABLET RAPID DISSOLVE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORAPRED ODT 15MG TABLET RAPID DISSOLVE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORAPRED ODT 30MG TABLET RAPID DISSOLVE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORENCIA 250MG VIAL |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | P Q:4 /30Days |
ORFADIN 10MG CAPSULE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORFADIN 2MG CAPSULE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORFADIN 5MG CAPSULE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORPHENADRINE CITRATE ASPIRIN AND CAFFEINE TABLET |
1 |
Preferred Generic |
15% | 15% | None |
ORPHENADRINE CITRATE ER TABLET 100MG (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORPHENADRINE CITRATE INJECTION 3030MG/ML 10ML VIAL |
1 |
Preferred Generic |
15% | 15% | None |
ORPHENADRINE COMP FORTE TABLET |
1 |
Preferred Generic |
15% | 15% | None |
ORPHENADRINE COMPOUND 25-385-30 TABLET |
1 |
Preferred Generic |
15% | 15% | None |
ORTHO EVRA DIS WEEK .75MG / 6MG |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | Q:3 /28Days |
ORTHO MICRON TABLET DIALPAK |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORTHO TRI-CYCLEN LO TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORTHO-CEPT 28 DAY TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORTHO-CYCLEN TABLET 0.25/35 |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORTHO-EST 0.625 TABLET |
1 |
Preferred Generic |
15% | 15% | None |
ORTHO-EST 1.25 TABLET |
1 |
Preferred Generic |
15% | 15% | None |
ORTHO-NOVUM 1/50-28 TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORTHO-NOVUM 7/7/7-28 TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
ORTHOCLONE OKT-3 5MG/5ML |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OSMOPREP TABLET 1.5GM |
2 |
Preferred Brand |
25% | 25% | None |
OTICIN HC 3.5-10K-1 SUSPENSION DROPS |
1 |
Preferred Generic |
15% | 15% | None |
OVCON-35 28 TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OVCON-50 28 TABLET |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OVIDE 0.5% LOTION |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OXACILLIN 1GM/50ML INJ |
1 |
Preferred Generic |
15% | 15% | None |
OXACILLIN 2GM/50ML INJ |
1 |
Preferred Generic |
15% | 15% | None |
OXACILLIN FOR INJECTION 1 GM |
1 |
Preferred Generic |
15% | 15% | None |
OXACILLIN FOR INJECTION 2 GM/VIAL |
1 |
Preferred Generic |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN INJECTION |
1 |
Preferred Generic |
15% | 15% | None |
OXACILLIN SODIUM FOR INJECTION 1 GM/VIAL |
1 |
Preferred Generic |
15% | 15% | None |
OXANDROLONE 10MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
OXANDROLONE 2.5MG TABLET |
2 |
Preferred Brand |
25% | 25% | Q:90 /30Days |
OXAPROZIN 600MG TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OXCARBAZEPINE 150MG TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
15% | 15% | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
15% | 15% | None |
OXISTAT 1% CREAM 30GM TUBE |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OXISTAT 1% LOTION |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OXSORALEN 1% LOTION |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXSORALEN-ULTRA 10MG CAP |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OXYBUTYNIN CHLORIDE SYRUP USP 5MG/5ML 5 ML UNIT DOSE CUP |
1 |
Preferred Generic |
15% | 15% | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Preferred Generic |
15% | 15% | Q:360 /30Days |
OXYCODONE HCL 15MG TABLET (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OXYCODONE HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OXYCODONE HCL ER TABLET |
1 |
Preferred Generic |
15% | 15% | Q:90 /30Days |
OXYCODONE HCL ER TABLETS 10MG 100 BOT |
1 |
Preferred Generic |
15% | 15% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER TABLETS 20MG 100 BOT |
1 |
Preferred Generic |
15% | 15% | Q:90 /30Days |
OXYCODONE HCL ER TABLETS 80MG 100 BOT |
1 |
Preferred Generic |
15% | 15% | Q:120 /30Days |
OXYCODONE HCL TABLET 30MG (100 CT) |
1 |
Preferred Generic |
15% | 15% | None |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
1 |
Preferred Generic |
15% | 15% | Q:360 /30Days |
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT) |
1 |
Preferred Generic |
15% | 15% | Q:240 /30Days |
OXYCODONE HCL-IBUPROFEN 400MG-5MG TABLET |
1 |
Preferred Generic |
15% | 15% | Q:240 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Preferred Generic |
15% | 15% | None |
OXYCODONE HYDROCHLORIDE TABLETS 20MG 100 BOT |
1 |
Preferred Generic |
15% | 15% | None |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Preferred Generic |
15% | 15% | Q:360 /30Days |
OXYCODONE/ASA 4.88/325 TABLET |
1 |
Preferred Generic |
15% | 15% | None |
OXYTROL 3.9MG/24HR PATCH |
3 |
Other - Non-Preferred (Gen/Brand) |
48% | 48% | Q:8 /28Days |