Q1Medicare.com 2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

2014 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-155-0) Benefit Details
The First Health Part D Value Plus (PDP) (S5768-155-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 32 which includes: CA Plan Monthly Premium: $41.60 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter O Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter O Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OCELLA 3MG/0.03MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD	4	Non-Preferred Brand	$88.00	N/A	P
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP	4	Non-Preferred Brand	$88.00	N/A	P
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP	4	Non-Preferred Brand	$88.00	N/A	P
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD	4	Non-Preferred Brand	$88.00	N/A	P
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP	4	Non-Preferred Brand	$88.00	N/A	P
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT	2	Non-Preferred Generic	$11.00	N/A	None
OFLOXACIN 0.3% EYE DROPS	2	Non-Preferred Generic	$11.00	N/A	None
Ofloxacin 200mg/1 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
Ofloxacin 300mg/1 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Ofloxacin 3mg/mL	2	Non-Preferred Generic	$11.00	N/A	None
OFLOXACIN 400MG TABLET (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
OGESTREL TABLET 0.05MG/0.5MG	4	Non-Preferred Brand	$88.00	N/A	None
OLANZAPINE 10 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
OLANZAPINE 10 MG VIAL [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	None
OLANZAPINE 15 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
OLANZAPINE 2.5 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
OLANZAPINE 20 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
OLANZAPINE 5 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
OLANZAPINE 7.5 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
OLANZAPINE ODT 10 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	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 [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
OLANZAPINE ODT 20 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
OLANZAPINE ODT 5 MG TABLET [Zyprexa]	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
OLANZAPINE-FLUOXETINE 12-25 MG	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
OLANZAPINE-FLUOXETINE 12-50 MG	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
olanzapine-fluoxetine 3-25 mg	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
OLANZAPINE-FLUOXETINE 6-25 MG	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
OLANZAPINE-FLUOXETINE 6-50 MG	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
OLSALAZINE 250 MG ORAL CAPSULE [DIPENTUM]	4	Non-Preferred Brand	$88.00	N/A	None
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT)	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG	1	Preferred Generic	$3.00	N/A	Q:60 /30Days
OMNARIS 50MCG SPRAY NON-AEROSOL	4	Non-Preferred Brand	$88.00	N/A	Q:13 /30Days
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM	4	Non-Preferred Brand	$88.00	N/A	P
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG	4	Non-Preferred Brand	$88.00	N/A	P
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG	4	Non-Preferred Brand	$88.00	N/A	P
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	33%	N/A	None
Ondansetron HCl 4 mg/2 ml vial	4	Non-Preferred Brand	$88.00	N/A	P
Ondansetron Hydrochloride 4mg/1	2	Non-Preferred Generic	$11.00	N/A	None
ONDANSETRON HYDROCHLORIDE 8MG TABLETS	2	Non-Preferred Generic	$11.00	N/A	None
ONFI 10 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	P Q:60 /30Days
ONFI 2.5 MG/ML SUSPENSION	4	Non-Preferred Brand	$88.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ONFI 20 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	P Q:60 /30Days
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA]	3	Preferred Brand	$37.00	N/A	P
OPSUMIT 10 MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
ORAP 1MG TABLET	3	Preferred Brand	$37.00	N/A	None
ORAP 2MG TABLET	3	Preferred Brand	$37.00	N/A	None
ORFADIN 10 MG CAPSULE	5	Specialty Tier	33%	N/A	P
ORFADIN 2 MG CAPSULE	5	Specialty Tier	33%	N/A	P
ORFADIN 5 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Ortho Evra 0.75; 6mg/7d; mg/7d 7 d in 1 PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:3 /28Days
OSMOPREP TABLET 1.5GM	4	Non-Preferred Brand	$88.00	N/A	None
OXACILLIN 1GM/50ML INJ	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXACILLIN 2GM/50ML INJ	4	Non-Preferred Brand	$88.00	N/A	None
OXACILLIN FOR INJECTION 1 GM	4	Non-Preferred Brand	$88.00	N/A	None
OXACILLIN INJECTION	4	Non-Preferred Brand	$88.00	N/A	None
oxandrolone 10mg/1 60 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	P Q:60 /30Days
OXANDROLONE 2.5MG TABLETS	2	Non-Preferred Generic	$11.00	N/A	P Q:120 /30Days
OXAPROZIN 600MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
oxazepam 10 mg capsule	2	Non-Preferred Generic	$11.00	N/A	Q:120 /30Days
Oxazepam 15mg/1	2	Non-Preferred Generic	$11.00	N/A	Q:120 /30Days
oxazepam 30 mg capsule	2	Non-Preferred Generic	$11.00	N/A	Q:120 /30Days
OXCARBAZEPINE 150MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT	2	Non-Preferred Generic	$11.00	N/A	None
OXISTAT 1% CREAM	4	Non-Preferred Brand	$88.00	N/A	None
OXISTAT 1% LOTION	4	Non-Preferred Brand	$88.00	N/A	None
OXSORALEN 1% LOTION	3	Preferred Brand	$37.00	N/A	None
OXSORALEN-ULTRA 10MG CAP	5	Specialty Tier	33%	N/A	None
OXYBUTYNIN 5MG TABLET	1	Preferred Generic	$3.00	N/A	None
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE	1	Preferred Generic	$3.00	N/A	None
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT)	4	Non-Preferred Brand	$88.00	N/A	S Q:60 /30Days
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT)	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
OXYCODONE HCL 100 MG/5 ML SOLN	2	Non-Preferred Generic	$11.00	N/A	None
OXYCODONE HCL 30MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:180 /30Days
OXYCODONE HCL 5 MG/5 ML SOLN	2	Non-Preferred Generic	$11.00	N/A	None
OXYCODONE HCL 5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	Q:180 /30Days
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	Q:180 /30Days
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
Oxycodone Hydrochloride and Ibuprofen 400; 5mg/1; mg/1 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$11.00	N/A	Q:28 /7Days
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:360 /30Days
oxymorphone hcl er 30 mg tab	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D First Health Part D Value 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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.