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2015 Medicare Part D Plan Formulary Information
Humana Preferred Rx Plan (PDP) (S5884-134-0) Benefit Details
The Humana Preferred Rx Plan (PDP) (S5884-134-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 9 which includes: SC Plan Monthly Premium: $29.00 Deductible: $320 Qualifies for LIS: Yes
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
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD	5	Specialty Tier	25%	N/A	P
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP	4	Non-Preferred Brand	35%	35%	P
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP	5	Specialty Tier	25%	N/A	P
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD	4	Non-Preferred Brand	35%	35%	P
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP	4	Non-Preferred Brand	35%	35%	P
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT	2	Non-Preferred Generic	$2.00	$0.00	None
OFEV 100 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:60 /30Days
OFEV 150 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:60 /30Days
OFLOXACIN 0.3% EYE DROPS	2	Non-Preferred Generic	$2.00	$0.00	None
OFLOXACIN 300 MG TABLET (50 CT)	3	Preferred Brand	20%	17%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Ofloxacin 3mg/mL	3	Preferred Brand	20%	17%	None
OFLOXACIN 400MG TABLET (100 CT)	3	Preferred Brand	20%	17%	None
OGESTREL TABLET 0.05MG/0.5MG	4	Non-Preferred Brand	35%	35%	None
OLANZAPINE 10 MG TABLET [Zyprexa]	3	Preferred Brand	20%	17%	Q:30 /30Days
OLANZAPINE 10 MG VIAL [Zyprexa]	3	Preferred Brand	20%	17%	Q:60 /30Days
OLANZAPINE 15 MG TABLET [Zyprexa]	3	Preferred Brand	20%	17%	Q:60 /30Days
OLANZAPINE 2.5 MG TABLET [Zyprexa]	3	Preferred Brand	20%	17%	Q:30 /30Days
OLANZAPINE 20 MG TABLET [Zyprexa]	3	Preferred Brand	20%	17%	Q:60 /30Days
OLANZAPINE 5 MG TABLET [Zyprexa]	3	Preferred Brand	20%	17%	Q:30 /30Days
OLANZAPINE 7.5 MG TABLET [Zyprexa]	3	Preferred Brand	20%	17%	Q:30 /30Days
OLANZAPINE ODT 10 MG TABLET [Zyprexa]	4	Non-Preferred Brand	35%	35%	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	35%	35%	Q:60 /30Days
OLANZAPINE ODT 20 MG TABLET [Zyprexa]	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
OLANZAPINE ODT 5 MG TABLET [Zyprexa]	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza]	3	Preferred Brand	20%	17%	Q:120 /30Days
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT)	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
OMEPRAZOLE 20mg DELAYED RELEASE 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG	2	Non-Preferred Generic	$2.00	$0.00	Q:30 /30Days
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM	5	Specialty Tier	25%	N/A	P
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG	5	Specialty Tier	25%	N/A	P
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG	5	Specialty Tier	25%	N/A	P
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ONDANSETRON 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL	3	Preferred Brand	20%	17%	None
ONDANSETRON 4 MG/2 ML ISECURE	3	Preferred Brand	20%	17%	None
ONDANSETRON HCL 24 MG TABLET	3	Preferred Brand	20%	17%	P Q:30 /30Days
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL	4	Non-Preferred Brand	35%	35%	P Q:450 /30Days
ONDANSETRON HYDROCHLORIDE 4MG	2	Non-Preferred Generic	$2.00	$0.00	P Q:90 /30Days
ONDANSETRON HYDROCHLORIDE 8MG TABLETS	2	Non-Preferred Generic	$2.00	$0.00	P Q:90 /30Days
ONDANSETRON ODT 4MG TABLET (30 CT)	3	Preferred Brand	20%	17%	P Q:90 /30Days
ONDANSETRON ODT 8MG (10 CT)	3	Preferred Brand	20%	17%	P Q:90 /30Days
ONFI 10 MG TABLET	4	Non-Preferred Brand	35%	35%	P Q:60 /30Days
ONFI 2.5 MG/ML SUSPENSION	4	Non-Preferred Brand	35%	35%	P Q:480 /30Days
ONFI 20 MG TABLET	4	Non-Preferred Brand	35%	35%	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ONGLYZA 2.5 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
ONGLYZA 5 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
OPDIVO 40 MG/4 ML VIAL	5	Specialty Tier	25%	N/A	P Q:80 /28Days
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA]	5	Specialty Tier	25%	N/A	Q:42 /30Days
OPSUMIT 10 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
ORAP 1MG TABLET	4	Non-Preferred Brand	35%	35%	None
ORAP 2MG TABLET	4	Non-Preferred Brand	35%	35%	None
ORFADIN 10 MG CAPSULE	5	Specialty Tier	25%	N/A	None
ORFADIN 2 MG CAPSULE	5	Specialty Tier	25%	N/A	None
ORFADIN 5 MG CAPSULE	5	Specialty Tier	25%	N/A	None
Orphenadrine Citrate 100mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Preferred Brand	20%	17%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	35%	35%	None
OSMOPREP TABLET 1.5GM	4	Non-Preferred Brand	35%	35%	None
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION	5	Specialty Tier	25%	N/A	None
oxandrolone 10mg/1 60 TABLET BOTTLE	5	Specialty Tier	25%	N/A	Q:60 /30Days
OXANDROLONE 2.5MG TABLETS	3	Preferred Brand	20%	17%	Q:120 /30Days
OXAPROZIN 600MG TABLET	4	Non-Preferred Brand	35%	35%	None
oxazepam 10 mg capsule	4	Non-Preferred Brand	35%	35%	None
Oxazepam 15mg/1	4	Non-Preferred Brand	35%	35%	None
oxazepam 30 mg capsule	4	Non-Preferred Brand	35%	35%	None
OXCARBAZEPINE 150MG TABLET	3	Preferred Brand	20%	17%	None
OXCARBAZEPINE 300 MG/5 ML SUSP	3	Preferred Brand	20%	17%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT	3	Preferred Brand	20%	17%	None
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT	3	Preferred Brand	20%	17%	None
OXSORALEN 1% LOTION	4	Non-Preferred Brand	35%	35%	None
OXSORALEN-ULTRA 10MG CAP	5	Specialty Tier	25%	N/A	None
OXYBUTYNIN 5MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	None
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R	3	Preferred Brand	20%	17%	Q:60 /30Days
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE	3	Preferred Brand	20%	17%	Q:60 /30Days
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE	2	Non-Preferred Generic	$2.00	$0.00	None
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT)	3	Preferred Brand	20%	17%	Q:60 /30Days
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT)	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT	3	Preferred Brand	20%	17%	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXYCODONE HCL 100 MG/5 ML SOLN	4	Non-Preferred Brand	35%	35%	Q:270 /30Days
OXYCODONE HCL 30MG TABLET	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE HCL 5 MG CAPSULE	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE HCL 5 MG/5 ML Solution	3	Preferred Brand	20%	17%	Q:5400 /30Days
OXYCODONE HCL 5MG TABLET	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE	3	Preferred Brand	20%	17%	Q:360 /30Days
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	Q:360 /30Days
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL	3	Preferred Brand	20%	17%	Q:360 /30Days
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET	3	Preferred Brand	20%	17%	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OXYCODONE-IBUPROFEN 5-400 TAB	4	Non-Preferred Brand	35%	35%	Q:240 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Humana Preferred Rx Plan (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 $320 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.