2010 Medicare Part D Plan Formulary Information |
AARP MedicareRx Enhanced (PDP) (S5921-093-0)
Benefit Details
|
The AARP MedicareRx Enhanced (PDP) (S5921-093-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 6 which includes: PA WV
|
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 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OCTAGAM IMMUNE GLOBULIN INTRAVENOUS HUMAN 5% S/D 50MG |
4 |
Tier 4 Specialty |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
4 |
Tier 4 Specialty |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
4 |
Tier 4 Specialty |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
4 |
Tier 4 Specialty |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
4 |
Tier 4 Specialty |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | P |
OCUFEN 0.03% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OCUFLOX 0.3% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OCUSULF-10 EYE DROPS |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OFLOXACIN 0.3% DROPS |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OFLOXACIN 200MG TABLET (50 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OFLOXACIN 300MG TABLET (50 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OFLOXACIN 400MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OGEN 0.625MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OGEN 1.5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OGEN 2.5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OLOPATADINE HCL 0.6% SPRAY SOLUTION NASAL SPRAY |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLUX-E 0.05% FOAM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | Q:31 /31Days |
OMEPRAZOLE 20MG CAPSULE DELAYED RELEASE |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | Q:124 /31Days |
OMEPRAZOLE DR CAPSULE |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | Q:31 /31Days |
OMNARIS 50MCG SPRAY NON-AEROSOL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:13 /31Days |
OMNICEF 125MG/5ML SUSP |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OMNICEF 300MG CAPSULE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OMNICEF SUS 250/5ML |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OMNIPRED OPHTHALMIC SUSPENSION 1% 10 ML BOTPL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
4 |
Tier 4 Specialty |
33% | 33% | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
4 |
Tier 4 Specialty |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
4 |
Tier 4 Specialty |
33% | 33% | P |
ONCASPAR 750UNIT/ML VIAL |
4 |
Tier 4 Specialty |
33% | 33% | None |
ONDANSETRON HCL 24MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P Q:3 /3Days |
ONDANSETRON HCL 4MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P Q:9 /3Days |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | P Q:100 /3Days |
ONDANSETRON HCL 8MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P Q:9 /3Days |
ONDANSETRON INJECTION 2MG 5X2ML VIAL |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | None |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P Q:9 /3Days |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P Q:9 /3Days |
ONTAK INJECTION 300MCG/2ML VIALSU |
4 |
Tier 4 Specialty |
33% | 33% | None |
ONXOL PACLITAXEL INJECTION 6MG/ML 5 ML VIALGL |
4 |
Tier 4 Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA 10MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:6 /1Days |
OPANA 5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:6 /1Days |
OPANA ER 10MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPANA ER 15MG TABLET SR 12HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPANA ER 20MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPANA ER 30MG TABLET SR 12HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPANA ER 40MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPANA ER 5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPANA ER 7.5MG TABLET SR 12HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
OPTIPRANOLOL 0.3% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OPTIVAR 0.05% DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORACEA CAPSULES 40MG 30 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
4 |
Tier 4 Specialty |
33% | 33% | P Q:4 /1Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
4 |
Tier 4 Specialty |
33% | 33% | P Q:4 /1Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
4 |
Tier 4 Specialty |
33% | 33% | P Q:4 /1Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
4 |
Tier 4 Specialty |
33% | 33% | P Q:4 /1Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
4 |
Tier 4 Specialty |
33% | 33% | P Q:4 /1Days |
ORAL TRANSMUCOSAL FENTANYL CITRATE LOZENGES |
4 |
Tier 4 Specialty |
33% | 33% | P Q:4 /1Days |
ORAMORPH SR 100MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:6 /1Days |
ORAMORPH SR 15MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
ORAMORPH SR 30MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
ORAMORPH SR 60MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORAP 1MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | None |
ORAP 2MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | None |
ORAPRED ODT 10MG TABLET 48 EA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORAPRED ODT TABLETS 15MG 14 PKG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORAPRED ODT TABLETS 30MG 14 CARD PKG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORAPRED SOLUTION 15MG/5ML 20 ML BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORENCIA 250MG VIAL |
4 |
Tier 4 Specialty |
33% | 33% | P |
ORFADIN 10MG CAPSULE |
4 |
Tier 4 Specialty |
33% | 33% | None |
ORFADIN 2MG CAPSULE |
4 |
Tier 4 Specialty |
33% | 33% | None |
ORFADIN 5MG CAPSULE |
4 |
Tier 4 Specialty |
33% | 33% | None |
ORPHENADRINE CITRATE ER TABLET 100MG (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | 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 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ORPHENADRINE COMP FORTE TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ORPHENADRINE COMPOUND 25-385-30 TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ORTHO EVRA DIS WEEK .75MG / 6MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORTHO MICRON TABLET DIALPAK |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORTHO NOVUM 7 7 7 28 TABLETS 0.035;1;0.MG;MG;MG 6 X 28 DLPK |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORTHO TRI-CYCLEN LO TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORTHO-CEPT 28 DAY TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORTHO-CYCLEN 28 TABLET 28 X 6 EA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ORTHO-EST 0.625 TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ORTHO-EST 1.25 TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORTHOCLONE OKT-3 5MG/5ML |
4 |
Tier 4 Specialty |
33% | 33% | P |
OSMOPREP TABLET 1.5GM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OVCON-35 28 TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OVCON-50 28 TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OVIDE 0.5% LOTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OXACILLIN 1GM/50ML INJ |
4 |
Tier 4 Specialty |
33% | 33% | None |
OXACILLIN 2GM/50ML INJ |
4 |
Tier 4 Specialty |
33% | 33% | None |
OXACILLIN FOR INJECTION 1 GM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OXACILLIN INJECTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OXANDRIN 10MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | P |
OXANDRIN 2.5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 10MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | P |
OXANDROLONE 2.5MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | P |
OXAPROZIN 600MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXCARBAZEPINE 150MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXISTAT 1% CREAM 30GM TUBE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OXISTAT 1% LOTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OXSORALEN 1% LOTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
OXSORALEN-ULTRA 10MG CAP |
4 |
Tier 4 Specialty |
33% | 33% | None |
OXYBUTYNIN 5MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | Q:62 /31Days |
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | Q:31 /31Days |
OXYBUTYNIN CHLORIDE SYRUP USP 5MG/5ML 5 ML UNIT DOSE CUP |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | Q:62 /31Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE AND ACETAMINOPHEN CAPSULES 500;5MG;MG 500 BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HCL 30MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HCL 5MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HCL ER TABLETS 10MG 100 BOT |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
OXYCODONE HCL ER TABLETS 20MG 100 BOT |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER TABLETS 80MG 100 BOT |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:6 /1Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HCL-IBUPROFEN 400MG-5MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HYDROCHLORIDE AND ACETAMINOPHEN TABLETS 650;10MG;MG 100 BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCODONE/ASA 4.88/325 TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
OXYCONTIN 10MG TABLET SA |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
OXYCONTIN 15MG TABLET SR 12HR |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
OXYCONTIN 20MG TABLET SA |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCONTIN 30MG TABLET SR 12HR |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
OXYCONTIN 40MG TABLET SA |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
OXYCONTIN 60MG TABLET SR 12HR |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:4 /1Days |
OXYCONTIN 80MG TABLET SA |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:6 /1Days |
OXYTROL 3.9MG/24HR PATCH |
2 |
Tier 2 Generic Preferred Brand |
$42.00 | $111.00 | Q:10 /31Days |