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Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Tier 1 (407)
Tier 2 (1277)
Tier 3 (451)
Tier 4 (270)
Tier 5 (604)
Tier 6 (434)
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Cick on the first letter of your drug name to browse the formulary:

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2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Benefit Details           
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Formulary Drugs Starting with the Letter O

in CMS PDP Region 32 which includes: CA
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 $7.00$10.50None
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD   6 Specialty Tier Drugs 33%N/ANone
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP   6 Specialty Tier Drugs 33%N/ANone
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP   6 Specialty Tier Drugs 33%N/ANone
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD   6 Specialty Tier Drugs 33%N/ANone
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP   5 Injectable Drug 33%33%None
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT   1 Preferred Generic Drugs $2.00$3.00None
Ofloxacin 200mg/1 100 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
OFLOXACIN 300MG TABLET (50 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
Ofloxacin 3mg/mL   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OFLOXACIN 400MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
OGESTREL TABLET 0.05MG/0.5MG   2 Non-Preferred Generic Drugs $7.00$10.50None
OLANZAPINE 10 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
OLANZAPINE 10 MG VIAL   5 Injectable Drug 33%33%None
OLANZAPINE 15 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
OLANZAPINE 2.5 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00Q:30
/30Days
OLANZAPINE 20 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00Q:90
/30Days
OLANZAPINE 5 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00Q:30
/30Days
OLANZAPINE 7.5 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00Q:30
/30Days
OLANZAPINE ODT 10 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OLANZAPINE ODT 15 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
OLANZAPINE ODT 20 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
OLANZAPINE ODT 5 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
Omeprazole 20mg/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
OMNARIS 50MCG SPRAY NON-AEROSOL   4 Non-Preferred Brand Drugs $90.00$225.00S Q:13
/30Days
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM   6 Specialty Tier Drugs 33%N/AP
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG   5 Injectable Drug 33%33%P
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG   5 Injectable Drug 33%33%P
ONDANSETRON HCL 24MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL   2 Non-Preferred Generic Drugs $7.00$10.50P Q:450
/30Days
Ondansetron Hydrochloride 4mg/1   2 Non-Preferred Generic Drugs $7.00$10.50P Q:90
/30Days
ONDANSETRON HYDROCHLORIDE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50P Q:90
/30Days
ONDANSETRON INJECTION 2MG 5X2ML VIAL   5 Injectable Drug 33%33%None
ONDANSETRON ODT 4MG TABLET (30 CT)   2 Non-Preferred Generic Drugs $7.00$10.50P Q:90
/30Days
ONDANSETRON ODT 8MG (10 CT)   2 Non-Preferred Generic Drugs $7.00$10.50P Q:90
/30Days
ONGLYZA 2.5mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
ONGLYZA 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
Onsolis 1200ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
Onsolis 200ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
Onsolis 400ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Onsolis 600ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
Onsolis 800ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
ONTAK INJECTION 300MCG/2ML VIALSU   6 Specialty Tier Drugs 33%N/AP
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA]   6 Specialty Tier Drugs 33%N/AP Q:21
/21Days
ORAP 1MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
ORAP 2MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
ORAVIG TABLETS   4 Non-Preferred Brand Drugs $90.00$225.00None
ORENCIA 125mg/mL 4 SYRINGE, GLASS in 1 CARTON / 1 mL in 1 SYRINGE, GLASS   6 Specialty Tier Drugs 33%N/AP Q:4
/28Days
ORENCIA 250MG VIAL   6 Specialty Tier Drugs 33%N/AP
ORFADIN CAPSULES 10 MG   6 Specialty Tier Drugs 33%N/ANone
ORFADIN CAPSULES 2 MG   6 Specialty Tier Drugs 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ORFADIN CAPSULES 5 MG   6 Specialty Tier Drugs 33%N/ANone
Orphenadrine Citrate 100mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Orphenadrine citrate 60mg/2mL 10 VIAL in 1 BOX / 2 mL in 1 VIAL   5 Injectable Drug 33%33%None
ORPHENADRINE COMP FORTE TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
ORPHENADRINE COMPOUND 25-385-30 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Orsythia 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
ORTHOCLONE OKT-3 5MG/5ML   6 Specialty Tier Drugs 33%N/AP
OSMOPREP TABLET 1.5GM   4 Non-Preferred Brand Drugs $90.00$225.00None
OXACILLIN 1GM/50ML INJ   5 Injectable Drug 33%33%None
OXACILLIN 2GM/50ML INJ   5 Injectable Drug 33%33%None
OXACILLIN FOR INJECTION 1 GM   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OXACILLIN INJECTION   5 Injectable Drug 33%33%None
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION   6 Specialty Tier Drugs 33%N/AP
OXANDROLONE 10MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
OXANDROLONE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
OXAPROZIN 600MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
OXCARBAZEPINE 150MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
OXCARBAZEPINE 60 MG/ML ORAL SUSPENSION   3 Preferred Brand Drugs $45.00$112.50None
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
OXSORALEN-ULTRA 10MG CAP   6 Specialty Tier Drugs 33%N/ANone
OXYBUTYNIN 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:360
/30Days
Oxycodone and Acetaminophen 650; 10mg/1; mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:180
/30Days
OXYCODONE AND ACETAMINOPHEN CAPSULES 500;5MG;MG 500 BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:240
/30Days
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:360
/30Days
OXYCODONE HCL 30MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
OXYCODONE HCL 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:360
/30Days
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)   2 Non-Preferred Generic Drugs $7.00$10.50Q:240
/30Days
Oxycodone Hydrochloride 100mg/5mL   2 Non-Preferred Generic Drugs $7.00$10.50None
Oxycodone Hydrochloride 5mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
Oxycodone Hydrochloride and Ibuprofen 400; 5mg/1; mg/1 100 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL   2 Non-Preferred Generic Drugs $7.00$10.50None
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:360
/30Days
OXYCODONE/ASA 4.88/325 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
OxyContin 10mg/1   4 Non-Preferred Brand Drugs $90.00$225.00S Q:90
/30Days
OxyContin 15mg/1   4 Non-Preferred Brand Drugs $90.00$225.00S Q:90
/30Days
OxyContin 20mg/1   4 Non-Preferred Brand Drugs $90.00$225.00S Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OxyContin 30mg/1   4 Non-Preferred Brand Drugs $90.00$225.00S Q:90
/30Days
OxyContin 40mg/1   4 Non-Preferred Brand Drugs $90.00$225.00S Q:90
/30Days
OxyContin 60mg/1   4 Non-Preferred Brand Drugs $90.00$225.00S Q:90
/30Days
OxyContin 80mg/1   6 Specialty Tier Drugs 33%N/AS Q:120
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $320 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2012 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.