2013 Medicare Part D Plan Formulary Information |
United American - Enhanced (PDP) (S5755-028-0)
Benefit Details
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The United American - Enhanced (PDP) (S5755-028-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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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 |
$7.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
5 |
Specialty |
29% | 29% | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
5 |
Specialty |
29% | 29% | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Ofloxacin 200mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Ofloxacin 300mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Ofloxacin 3mg/mL |
2* |
Non-Preferred Generic |
$7.00 | $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) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OLANZAPINE 10 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE 10 MG VIAL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OLANZAPINE 15 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE 2.5 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE 20 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE 5 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE 7.5 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE ODT 10 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
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 |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE ODT 20 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE ODT 5 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE-FLUOXETINE 12-25 MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE-FLUOXETINE 12-50 MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
olanzapine-fluoxetine 3-25 mg |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE-FLUOXETINE 6-25 MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLANZAPINE-FLUOXETINE 6-50 MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OLSALAZINE 250 MG ORAL CAPSULE [DIPENTUM] |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE CAPSULES |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OMEPRAZOLE CAPSULES |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ONDANSETRON HCL 24 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:21 /90Days |
Ondansetron HCl 4 mg/2 ml vial |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P |
Ondansetron Hydrochloride 4mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:135 /90Days |
ONDANSETRON HYDROCHLORIDE TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:135 /90Days |
ONDANSETRON ODT 4MG TABLET (30 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:135 /90Days |
ONDANSETRON ODT 8MG (10 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:135 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 10 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
ONFI 20 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
ONFI 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
ONGLYZA 2.5mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
ONGLYZA 5mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
Onsolis 1200ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
3 |
Preferred Brand |
$40.00 | $90.00 | P Q:360 /90Days |
Onsolis 200ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
3 |
Preferred Brand |
$40.00 | $90.00 | P Q:720 /90Days |
Onsolis 400ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
3 |
Preferred Brand |
$40.00 | $90.00 | P Q:360 /90Days |
Onsolis 600ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
3 |
Preferred Brand |
$40.00 | $90.00 | P Q:360 /90Days |
Onsolis 800ug/1 30 PACKAGE in 1 CARTON / 1 FILM, SOLUBLE in 1 PACKAGE |
3 |
Preferred Brand |
$40.00 | $90.00 | P Q:360 /90Days |
ONTAK INJECTION 300MCG/2ML VIALSU |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA ER 10 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OPANA ER 20 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OPANA ER 30 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OPANA ER 40 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OPANA ER 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA] |
5 |
Specialty |
29% | 29% | P Q:63 /90Days |
ORAP 1MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
ORAP 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
ORENCIA 125mg/mL 4 SYRINGE, GLASS in 1 CARTON / 1 mL in 1 SYRINGE, GLASS |
5 |
Specialty |
29% | 29% | P Q:12 /90Days |
ORFADIN CAPSULES 10 MG |
5 |
Specialty |
29% | 29% | None |
ORFADIN CAPSULES 2 MG |
5 |
Specialty |
29% | 29% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORFADIN CAPSULES 5 MG |
5 |
Specialty |
29% | 29% | None |
Orsythia 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Ortho Evra 0.75; 6mg/7d; mg/7d 7 d in 1 PATCH |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty |
29% | 29% | None |
OXANDROLONE 10MG TABLET |
5 |
Specialty |
29% | 29% | P |
OXANDROLONE TABLETS |
3 |
Preferred Brand |
$40.00 | $90.00 | P |
OXAPROZIN 600MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXCARBAZEPINE 150MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXSORALEN-ULTRA 10MG CAP |
5 |
Specialty |
29% | 29% | None |
OXYBUTYNIN 5MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:360 /90Days |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1080 /90Days |
Oxycodone and Acetaminophen 650; 10mg 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:540 /90Days |
OXYCODONE AND ACETAMINOPHEN CAPSULES 500;5MG;MG 500 BOT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:720 /90Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1080 /90Days |
OXYCODONE HCL 30MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:540 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 5 MG/5 ML SOL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:3600 /90Days |
OXYCODONE HCL 5MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1080 /90Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1080 /90Days |
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:720 /90Days |
Oxycodone Hydrochloride 100mg/5mL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1800 /90Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:540 /90Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:540 /90Days |
Oxycodone Hydrochloride 5mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1080 /90Days |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:540 /90Days |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:1080 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
OxyContin 80mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXYMORPHONE HYDROCHLORIDE TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
OXYMORPHONE HYDROCHLORIDE TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:32 /90Days |