2015 Medicare Part D Plan Formulary Information |
KelseyCare Advantage Rx Premier (HMO) (H0332-006-0)
Benefit Details
|
The KelseyCare Advantage Rx Premier (HMO) (H0332-006-0) Formulary Drugs Starting with the Letter O in HARRIS County, TX: CMS MA Region 17 which includes: TX Plan Monthly Premium: $221.00 Deductible: $50 |
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 3MG/0.03MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
5 |
Specialty Tier |
30% | N/A | P |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
2 |
Non-Preferred Generic |
$20.00 | N/A | P |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
5 |
Specialty Tier |
30% | N/A | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
2 |
Non-Preferred Generic |
$20.00 | N/A | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
2 |
Non-Preferred Generic |
$20.00 | N/A | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
OFLOXACIN 0.3% EYE DROPS |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OFLOXACIN 300 MG TABLET (50 CT) |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
Ofloxacin 3mg/mL |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OFLOXACIN 400MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OGESTREL TABLET 0.05MG/0.5MG |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 10 MG VIAL [Zyprexa] |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-50 MG |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
olanzapine-fluoxetine 3-25 mg |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-25 MG |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:90 /30Days |
OLANZAPINE-FLUOXETINE 6-50 MG |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
OLYSIO 150 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
OMECLAMOX-PAK COMBO PACK |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OMEPRAZOLE 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | Q:60 /30Days |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
1 |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
OMEPRAZOLE-BICARB 20-1,100 CAP |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OMEPRAZOLE-BICARB 40-1,100 CAP |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Specialty Tier |
30% | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
30% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
4 |
Non-Preferred Brand |
$50.00 | N/A | P |
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
30% | N/A | None |
ONDANSETRON 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL |
1 |
Preferred Generic |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON 4 MG/2 ML ISECURE |
1 |
Preferred Generic |
$0.00 | N/A | P |
ONDANSETRON HCL 24 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | P Q:18 /30Days |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
1 |
Preferred Generic |
$0.00 | N/A | P Q:450 /30Days |
ONDANSETRON HYDROCHLORIDE 4MG |
1 |
Preferred Generic |
$0.00 | N/A | P Q:90 /30Days |
ONDANSETRON HYDROCHLORIDE 8MG TABLETS |
1 |
Preferred Generic |
$0.00 | N/A | P Q:90 /30Days |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Preferred Generic |
$0.00 | N/A | P Q:90 /30Days |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Preferred Generic |
$0.00 | N/A | P Q:90 /30Days |
ONFI 10 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
ONFI 20 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$20.00 | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$20.00 | N/A | S Q:30 /30Days |
ONMEL 200 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | P |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
30% | N/A | P |
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA] |
5 |
Specialty Tier |
30% | N/A | P |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
ORACEA CAPSULES 40MG 30 BOT |
3 |
Preferred Brand |
$20.00 | N/A | None |
ORAP 1MG TABLET |
3 |
Preferred Brand |
$20.00 | N/A | None |
ORAP 2MG TABLET |
3 |
Preferred Brand |
$20.00 | N/A | None |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
30% | N/A | P |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
30% | N/A | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENITRAM ER 0.25 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | P |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | None |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$0.00 | N/A | None |
OSMOPREP TABLET 1.5GM |
3 |
Preferred Brand |
$20.00 | N/A | None |
Otezla 10-20-30MG |
5 |
Specialty Tier |
30% | N/A | P |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
30% | N/A | P |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty Tier |
30% | N/A | None |
oxandrolone 10mg/1 60 TABLET BOTTLE |
5 |
Specialty Tier |
30% | N/A | P Q:60 /30Days |
OXANDROLONE 2.5MG TABLETS |
2 |
Non-Preferred Generic |
$20.00 | N/A | P Q:120 /30Days |
OXAPROZIN 600MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OXCARBAZEPINE 150MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXISTAT 1% CREAM |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
2 |
Non-Preferred Generic |
$20.00 | N/A | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Preferred Generic |
$0.00 | N/A | Q:360 /30Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:360 /30Days |
OXYCODONE HCL 30MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYCODONE HCL 5 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYCODONE HCL 5 MG/5 ML Solution |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYCODONE HCL 5MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYCODONE HCL ER 10 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 20 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | P Q:62 /31Days |
OXYCODONE HCL ER 40 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | P Q:62 /31Days |
OXYCODONE HCL ER 80 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:124 /31Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
1 |
Preferred Generic |
$0.00 | N/A | None |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:360 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:150 /30Days |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$20.00 | N/A | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$20.00 | N/A | P Q:62 /31Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$20.00 | N/A | P Q:62 /31Days |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$20.00 | N/A | P Q:62 /31Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$20.00 | N/A | P Q:62 /31Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$20.00 | N/A | P Q:62 /31Days |
OxyContin 80mg/1 |
5 |
Specialty Tier |
30% | N/A | P Q:124 /31Days |
oxymorphone hcl er 10 mg tab |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
oxymorphone hcl er 20 mg tab |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
oxymorphone hcl er 30 mg tab |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
oxymorphone hcl er 40 mg tab |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
oxymorphone hcl er 5 mg tablet |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYMORPHONE HYDROCHLORIDE 10MG TABLETS |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:240 /30Days |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
OXYMORPHONE HYDROCHLORIDE 5MG TABLETS |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:480 /30Days |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | N/A | Q:60 /30Days |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH |
3 |
Preferred Brand |
$20.00 | N/A | S Q:8 /28Days |