2016 Medicare Part D Plan Formulary Information |
New West Medicare Basic (PPO) (H2701-006-0)
Benefit Details
|
The New West Medicare Basic (PPO) (H2701-006-0) Formulary Drugs Starting with the Letter O in Ravalli County, MT: CMS MA Region 19 which includes: MT Plan Monthly Premium: $36.50 Deductible: $0 |
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 |
Generic |
$15.00 | $30.00 | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
5 |
Specialty Tier |
33% | N/A | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
2 |
Generic |
$15.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
2 |
Generic |
$15.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
2 |
Generic |
$15.00 | $30.00 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
2 |
Generic |
$15.00 | $30.00 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
OFLOXACIN 0.3 % DRP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OFLOXACIN 0.3% EAR DROPS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OFLOXACIN 400MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:31 /30Days |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | $30.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG |
2 |
Generic |
$15.00 | $30.00 | None |
OLANZAPINE-FLUOXETINE 12-50 MG |
2 |
Generic |
$15.00 | $30.00 | None |
olanzapine-fluoxetine 3-25 mg |
2 |
Generic |
$15.00 | $30.00 | None |
OLANZAPINE-FLUOXETINE 6-25 MG |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE-FLUOXETINE 6-50 MG |
2 |
Generic |
$15.00 | $30.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
2 |
Generic |
$15.00 | $30.00 | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2 |
Generic |
$15.00 | $30.00 | None |
OLYSIO 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
2 |
Generic |
$15.00 | $30.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | N/A | P |
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ONDANSETRON 4 MG/2 ML ISECURE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 24 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
2 |
Generic |
$15.00 | $30.00 | P |
ONDANSETRON HCL 8 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Ondansetron Hydrochloride 4mg/1 |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
ONDANSETRON ODT 4MG TABLET (30 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
ONDANSETRON ODT 8MG (10 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
ONFI 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:480 /30Days |
ONFI 20 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /30Days |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 0.125 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
ORENITRAM ER 0.25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
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 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
OTREXUP 7.5 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
OXACILLIN 10 GM VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
OXACILLIN 1GM/50ML INJ |
2 |
Generic |
$15.00 | $30.00 | None |
Oxacillin 2 gm add-vantage vl |
2 |
Generic |
$15.00 | $30.00 | None |
OXACILLIN 2GM/50ML INJ |
2 |
Generic |
$15.00 | $30.00 | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
oxandrolone 10mg/1 60 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 2.5MG TABLETS |
2 |
Generic |
$15.00 | $30.00 | None |
OXCARBAZEPINE 150MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
OXTELLAR XR 600 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R |
2 |
Generic |
$15.00 | $30.00 | None |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:360 /30Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
OXYCODONE HCL 30MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
OXYCODONE HCL 5 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | Q:180 /30Days |
OXYCODONE HCL 5 MG/5 ML Solution |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:1300 /30Days |
OXYCODONE HCL 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
OXYCODONE HCL ER 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYCODONE HCL ER 15 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 20 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYCODONE HCL ER 30 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYCODONE HCL ER 40 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYCODONE HCL ER 60 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYCODONE HCL ER 80 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
Oxycodone-Acetaminophen 5-325/5 |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:1800 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:360 /30Days |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
OxyContin 80mg/1 |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:120 /30Days |
oxymorphone hcl er 10 mg tab |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
oxymorphone hcl er 20 mg tab |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
oxymorphone hcl er 30 mg tab |
2 |
Generic |
$15.00 | $30.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxymorphone hcl er 40 mg tab |
2 |
Generic |
$15.00 | $30.00 | Q:120 /30Days |
oxymorphone hcl er 5 mg tablet |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYMORPHONE HYDROCHLORIDE 10MG TABLETS |
2 |
Generic |
$15.00 | $30.00 | Q:180 /30Days |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
OXYMORPHONE HYDROCHLORIDE 5MG TABLETS |
2 |
Generic |
$15.00 | $30.00 | Q:180 /30Days |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |