2013 Medicare Part D Plan Formulary Information |
Community HealthFirst MA Pharmacy Plan (HMO) (H5826-008-0)
Benefit Details
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The Community HealthFirst MA Pharmacy Plan (HMO) (H5826-008-0) Formulary Drugs Starting with the Letter O in SPOKANE County, WA: CMS MA Region 23 which includes: WA
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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 |
$10.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
3 |
Specialty Tier |
33% | 33% | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
3 |
Specialty Tier |
33% | 33% | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
3 |
Specialty Tier |
33% | 33% | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Ofloxacin 200mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Ofloxacin 300mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Ofloxacin 3mg/mL |
1 |
Preferred Generic |
$10.00 | $30.00 | 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 |
$10.00 | $30.00 | None |
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OLANZAPINE 10 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:68 /34Days |
OLANZAPINE 10 MG VIAL |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OLANZAPINE 15 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:45 /34Days |
OLANZAPINE 2.5 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:272 /34Days |
OLANZAPINE 20 MG TABLET |
3 |
Specialty Tier |
33% | 33% | Q:34 /34Days |
OLANZAPINE 5 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:136 /34Days |
OLANZAPINE 7.5 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:91 /34Days |
OLANZAPINE ODT 10 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:68 /34Days |
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 |
$10.00 | $30.00 | Q:45 /34Days |
OLANZAPINE ODT 20 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:34 /34Days |
OLANZAPINE ODT 5 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:136 /34Days |
OLANZAPINE-FLUOXETINE 12-25 MG |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OLANZAPINE-FLUOXETINE 12-50 MG |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
olanzapine-fluoxetine 3-25 mg |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OLANZAPINE-FLUOXETINE 6-25 MG |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OLANZAPINE-FLUOXETINE 6-50 MG |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:34 /34Days |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:34 /34Days |
OMEPRAZOLE CAPSULES |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:34 /34Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE CAPSULES |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
3 |
Specialty Tier |
33% | 33% | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
2 |
Preferred Brand |
$50.00 | $150.00 | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
2 |
Preferred Brand |
$50.00 | $150.00 | P |
ONDANSETRON HCL 24 MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | P Q:1 /1Days |
Ondansetron HCl 4 mg/2 ml vial |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
1 |
Preferred Generic |
$10.00 | $30.00 | P Q:150 /5Days |
Ondansetron Hydrochloride 4mg/1 |
1 |
Preferred Generic |
$10.00 | $30.00 | P Q:12 /5Days |
ONDANSETRON HYDROCHLORIDE TABLETS |
1 |
Preferred Generic |
$10.00 | $30.00 | P Q:12 /5Days |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | P Q:12 /5Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | P Q:12 /5Days |
ONFI 10 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | P |
ONFI 20 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | P |
ONFI 5 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | P |
ONGLYZA 2.5mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$50.00 | $150.00 | Q:34 /34Days |
ONGLYZA 5mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$50.00 | $150.00 | Q:34 /34Days |
OPANA ER 10 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OPANA ER 20 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OPANA ER 30 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OPANA ER 40 MG TABLET |
3 |
Specialty Tier |
33% | 33% | S Q:90 /30Days |
OPANA ER 5 MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA] |
3 |
Specialty Tier |
33% | 33% | Q:21 /21Days |
ORAP 1MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | None |
ORAP 2MG TABLET |
2 |
Preferred Brand |
$50.00 | $150.00 | None |
ORENCIA 125mg/mL 4 SYRINGE, GLASS in 1 CARTON / 1 mL in 1 SYRINGE, GLASS |
3 |
Specialty Tier |
33% | 33% | P |
ORENCIA 250MG VIAL |
3 |
Specialty Tier |
33% | 33% | P |
ORFADIN CAPSULES 10 MG |
3 |
Specialty Tier |
33% | 33% | None |
ORFADIN CAPSULES 2 MG |
3 |
Specialty Tier |
33% | 33% | None |
ORFADIN CAPSULES 5 MG |
3 |
Specialty Tier |
33% | 33% | None |
Orphenadrine Citrate 100mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
Orphenadrine citrate 60mg/2mL 10 VIAL in 1 BOX / 2 mL in 1 VIAL |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Orphenadrine Citrate, Aspirin and Caffeine 385; 30; 25mg/1; mg/1; mg/1 100 TABLET, MULTILAYER in 1 |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORPHENADRINE COMP FORTE TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
Orsythia 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXACILLIN 1GM/50ML INJ |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXACILLIN 2GM/50ML INJ |
3 |
Specialty Tier |
33% | 33% | None |
OXACILLIN FOR INJECTION 1 GM |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXACILLIN INJECTION |
3 |
Specialty Tier |
33% | 33% | None |
OXANDROLONE 10MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
OXANDROLONE TABLETS |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
OXAPROZIN 600MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
oxazepam 10 mg capsule |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
Oxazepam 15mg/1 |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxazepam 30 mg capsule |
1 |
Preferred Generic |
$10.00 | $30.00 | P |
OXCARBAZEPINE 150MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXSORALEN 1% LOTION |
2 |
Preferred Brand |
$50.00 | $150.00 | None |
OXSORALEN-ULTRA 10MG CAP |
3 |
Specialty Tier |
33% | 33% | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:34 /34Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Oxycodone and Acetaminophen 650; 10mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE AND ACETAMINOPHEN CAPSULES 500;5MG;MG 500 BOT |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HCL 30MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HCL 5 MG/5 ML SOL |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HCL 5MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Oxycodone Hydrochloride 100mg/5mL |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Oxycodone Hydrochloride 5mg/1 |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Oxycodone Hydrochloride and Ibuprofen 400; 5mg/1; mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
OxyContin 10mg/1 |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OxyContin 15mg/1 |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OxyContin 20mg/1 |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OxyContin 30mg/1 |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 40mg/1 |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OxyContin 60mg/1 |
2 |
Preferred Brand |
$50.00 | $150.00 | S Q:90 /30Days |
OxyContin 80mg/1 |
3 |
Specialty Tier |
33% | 33% | S Q:90 /30Days |
oxymorphone hcl er 10 mg tab |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
oxymorphone hcl er 20 mg tab |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
oxymorphone hcl er 30 mg tab |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
oxymorphone hcl er 40 mg tab |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
oxymorphone hcl er 5 mg tablet |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
OXYMORPHONE HYDROCHLORIDE TABLETS |
1 |
Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYMORPHONE HYDROCHLORIDE TABLETS |
1 |
Preferred Generic |
$10.00 | $30.00 | None |