2012 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan One (PDP) (S5617-103-0)
Benefit Details
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The CIGNA Medicare Rx Plan One (PDP) (S5617-103-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 21 which includes: LA
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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 |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
5 |
Specialty Tier Drugs |
25% | 25% | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
5 |
Specialty Tier Drugs |
25% | 25% | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
Ofloxacin 200mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OFLOXACIN 300MG TABLET (50 CT) |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
Ofloxacin 3mg/mL |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OFLOXACIN 400MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OLANZAPINE 10 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OLANZAPINE 15 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE 20 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE 5 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE ODT 15 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-50MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-50MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6/25MG CAP 3 |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:30 /30Days |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:60 /30Days |
Omeprazole 20mg/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:60 /30Days |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | Q:60 /30Days |
OMNARIS 50MCG SPRAY NON-AEROSOL |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | 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 |
5 |
Specialty Tier Drugs |
25% | 25% | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | P |
ONDANSETRON HCL 24MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P Q:5 /30Days |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P Q:900 /30Days |
Ondansetron Hydrochloride 4mg/1 |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P Q:60 /30Days |
ONDANSETRON HYDROCHLORIDE TABLETS |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P Q:90 /30Days |
ONDANSETRON INJECTION 2MG 5X2ML VIAL |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P Q:60 /30Days |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | P Q:90 /30Days |
ONGLYZA 2.5mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONGLYZA 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:30 /30Days |
Onsolis 1200ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:120 /30Days |
Onsolis 200ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:120 /30Days |
Onsolis 400ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:120 /30Days |
Onsolis 600ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:120 /30Days |
Onsolis 800ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:120 /30Days |
ONTAK INJECTION 300MCG/2ML VIALSU |
5 |
Specialty Tier Drugs |
25% | 25% | P |
OPANA ER 10 MG TABLET |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:60 /30Days |
OPANA ER 20 MG TABLET |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:60 /30Days |
OPANA ER 30 MG TABLET |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:60 /30Days |
OPANA ER 40 MG TABLET |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA ER 5 MG TABLET |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:60 /30Days |
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA] |
5 |
Specialty Tier Drugs |
25% | 25% | P |
OPTIPRANOLOL 0.3% EYE DROPS |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
ORACEA CAPSULES 40MG 30 BOT |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
ORAP 1MG TABLET |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
ORAP 2MG TABLET |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
ORENCIA 250MG VIAL |
5 |
Specialty Tier Drugs |
25% | 25% | P |
ORFADIN CAPSULES 10 MG |
5 |
Specialty Tier Drugs |
25% | 25% | None |
ORFADIN CAPSULES 2 MG |
5 |
Specialty Tier Drugs |
25% | 25% | None |
ORFADIN CAPSULES 5 MG |
5 |
Specialty Tier Drugs |
25% | 25% | None |
Orsythia 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ortho Evra 0.75; 6mg/7d; mg/7d 7 d in 1 PATCH |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
ORTHO-EST 0.625 TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
ORTHO-EST 1.25 TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
ORTHOCLONE OKT-3 5MG/5ML |
5 |
Specialty Tier Drugs |
25% | 25% | P |
OVIDE 0.005g/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
OXACILLIN 1GM/50ML INJ |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXACILLIN 2GM/50ML INJ |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXACILLIN FOR INJECTION 1 GM |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXACILLIN INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty Tier Drugs |
25% | 25% | P |
OXANDRIN 2.5MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 10MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | None |
OXANDROLONE TABLETS |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXAPROZIN 600MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXCARBAZEPINE 150MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXCARBAZEPINE 60 MG/ML ORAL SUSPENSION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXSORALEN 1% LOTION |
4 |
Non-Preferred Brand Drugs |
$74.00 | $185.00 | None |
OXSORALEN-ULTRA 10MG CAP |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | 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) |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:60 /30Days |
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:30 /30Days |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:60 /30Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
Oxycodone and Acetaminophen 650; 10mg/1; mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXYCODONE AND ACETAMINOPHEN CAPSULES 500;5MG;MG 500 BOT |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXYCODONE HCL 30MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXYCODONE HCL 5MG TABLET |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Oxycodone Hydrochloride 100mg/5mL |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
Oxycodone Hydrochloride 5mg/1 |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
Oxycodone Hydrochloride and Ibuprofen 400; 5mg/1; mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
1 |
Preferred Generic Drugs |
$3.00 | $7.50 | None |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OXYCODONE/ASA 4.88/325 TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
OxyContin 10mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:90 /30Days |
OxyContin 15mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:90 /30Days |
OxyContin 20mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:90 /30Days |
OxyContin 30mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 40mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:90 /30Days |
OxyContin 60mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:90 /30Days |
OxyContin 80mg/1 |
3 |
Preferred Brand Drugs |
$31.00 | $77.50 | Q:120 /30Days |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:60 /30Days |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:60 /30Days |