2015 Medicare Part D Plan Formulary Information |
UnitedHealthcare Assisted Living Plan (HMO SNP) (H3794-003-0)
Benefit Details
|
The UnitedHealthcare Assisted Living Plan (HMO SNP) (H3794-003-0) Formulary Drugs Starting with the Letter O in WINNEBAGO County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $11.70 Deductible: $235 |
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 |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OCTAGAM 10% VIAL |
5* |
Specialty Tier |
33% | 33% | P |
OCTAGAM 5% VIAL |
5* |
Specialty Tier |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
5* |
Specialty Tier |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
5* |
Specialty Tier |
33% | 33% | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OFEV 100 MG CAPSULE |
5* |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OFEV 150 MG CAPSULE |
5* |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
OFLOXACIN 0.3% EYE DROPS |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OFLOXACIN 300 MG TABLET (50 CT) |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Ofloxacin 3mg/mL |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OFLOXACIN 400MG TABLET (100 CT) |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL [Zyprexa] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OLOPATADINE 665 MCG NASAL SPRY |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OLYSIO 150 MG CAPSULE |
5* |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | None |
OMEPRAZOLE 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:60 /30Days |
OMNARIS 50MCG SPRAY NON-AEROSOL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5* |
Specialty Tier |
33% | 33% | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5* |
Specialty Tier |
33% | 33% | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5* |
Specialty Tier |
33% | 33% | P |
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5* |
Specialty Tier |
33% | 33% | None |
ONDANSETRON 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ONDANSETRON 4 MG/2 ML ISECURE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ONDANSETRON HCL 24 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | P |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
ONDANSETRON HYDROCHLORIDE 4MG |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HYDROCHLORIDE 8MG TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | P |
ONDANSETRON ODT 4MG TABLET (30 CT) |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | P |
ONDANSETRON ODT 8MG (10 CT) |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | P |
ONFI 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ONFI 20 MG TABLET |
5* |
Specialty Tier |
33% | 33% | Q:60 /30Days |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
ONMEL 200 MG TABLET |
5* |
Specialty Tier |
33% | 33% | P |
OPANA ER 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
OPANA ER 15 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA ER 20 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
OPANA ER 30 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days |
OPANA ER 40 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
OPANA ER 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
OPANA ER 7.5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
OPDIVO 40 MG/4 ML VIAL |
5* |
Specialty Tier |
33% | 33% | P |
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA] |
5* |
Specialty Tier |
33% | 33% | P |
OPSUMIT 10 MG TABLET |
5* |
Specialty Tier |
33% | 33% | P |
ORAP 1MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
ORAP 2MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
ORENCIA 125 MG/ML SYRINGE |
5* |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENCIA 250MG VIAL |
5* |
Specialty Tier |
33% | 33% | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:180 /30Days |
ORENITRAM ER 0.25 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:180 /30Days |
ORENITRAM ER 1 MG TABLET |
5* |
Specialty Tier |
33% | 33% | P Q:180 /30Days |
ORENITRAM ER 2.5 MG TABLET |
5* |
Specialty Tier |
33% | 33% | P |
ORFADIN 10 MG CAPSULE |
5* |
Specialty Tier |
33% | 33% | None |
ORFADIN 2 MG CAPSULE |
5* |
Specialty Tier |
33% | 33% | None |
ORFADIN 5 MG CAPSULE |
5* |
Specialty Tier |
33% | 33% | None |
Orphenadrine 30 mg/ml vial |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Ortho Cept 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ortho Cyclen 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Ortho Micronor 0.35mg/1 6 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Ortho Novum 135 6 DIALPACK in 1 CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
ORTHO TRI CYCLEN Lo 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Ortho Tri-Cyclen 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Ortho-Novum 777 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days |
Otezla 10-20-30MG |
5* |
Specialty Tier |
33% | 33% | P |
OTEZLA 28 DAY STARTER PACK |
5* |
Specialty Tier |
33% | 33% | P |
OTEZLA 30 MG TABLET |
5* |
Specialty Tier |
33% | 33% | P |
OVCON 35 72 CARTON in 1 CASE / 3 CELLO PACK per CARTON / 1 BLISTER PACK in 1 CELLO PACK / 1 KIT i |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OXACILLIN 10 GM VIAL |
5* |
Specialty Tier |
33% | 33% | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Oxacillin 2 gm add-vantage vl |
5* |
Specialty Tier |
33% | 33% | None |
OXACILLIN 2GM/50ML INJ |
5* |
Specialty Tier |
33% | 33% | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
5* |
Specialty Tier |
33% | 33% | None |
oxandrolone 10mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 2.5MG TABLETS |
3 |
Preferred Brand |
$45.00 | $125.00 | P |
OXAPROZIN 600MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | None |
OXCARBAZEPINE 150MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OXISTAT 1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
OXSORALEN 1% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
OXSORALEN-ULTRA 10MG CAP |
5* |
Specialty Tier |
33% | 33% | P |
OXYBUTYNIN 5MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | 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 |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days |
OXYCODONE HCL 30MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:240 /30Days |
OXYCODONE HCL 5 MG CAPSULE |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG/5 ML Solution |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:7200 /30Days |
OXYCODONE HCL 5MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:360 /30Days |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
2* |
Non-Preferred Generic |
$7.00 | $14.00 | Q:480 /30Days |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days |
OXYMORPHONE HYDROCHLORIDE 10MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:180 /30Days |
OXYMORPHONE HYDROCHLORIDE 5MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:180 /30Days |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH |
3 |
Preferred Brand |
$45.00 | $125.00 | None |