2016 Medicare Part D Plan Formulary Information |
Medicare Blue Choice Select (HMO-POS) (H3351-016-0)
Benefit Details
|
The Medicare Blue Choice Select (HMO-POS) (H3351-016-0) Formulary Drugs Starting with the Letter O in Monroe County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $0.00 Deductible: $360 |
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 |
$12.00 | $30.00 | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
25% | 25% | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
25% | 25% | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD |
5 |
Specialty Tier |
25% | 25% | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP |
5 |
Specialty Tier |
25% | 25% | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2* |
Generic |
$12.00 | $30.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
2* |
Generic |
$12.00 | $30.00 | None |
OFLOXACIN 0.3% EAR DROPS |
2* |
Generic |
$12.00 | $30.00 | None |
OFLOXACIN 400MG TABLET (100 CT) |
2* |
Generic |
$12.00 | $30.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2* |
Generic |
$12.00 | $30.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2* |
Generic |
$12.00 | $30.00 | None |
OLANZAPINE 10 MG VIAL [Zyprexa] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2* |
Generic |
$12.00 | $30.00 | None |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2* |
Generic |
$12.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2* |
Generic |
$12.00 | $30.00 | None |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2* |
Generic |
$12.00 | $30.00 | None |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2* |
Generic |
$12.00 | $30.00 | None |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OLANZAPINE-FLUOXETINE 12-25 MG |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OLANZAPINE-FLUOXETINE 12-50 MG |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
olanzapine-fluoxetine 3-25 mg |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OLANZAPINE-FLUOXETINE 6-25 MG |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE-FLUOXETINE 6-50 MG |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2* |
Generic |
$12.00 | $30.00 | None |
OLYSIO 150 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
2* |
Generic |
$12.00 | $30.00 | Q:120 /30Days |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
2* |
Generic |
$12.00 | $30.00 | Q:60 /30Days |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
2* |
Generic |
$12.00 | $30.00 | Q:120 /30Days |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
2* |
Generic |
$12.00 | $30.00 | Q:60 /30Days |
OMEPRAZOLE-BICARB 20-1,100 CAP |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days |
OMEPRAZOLE-BICARB 40-1,100 CAP |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days |
OMNARIS 50MCG SPRAY NON-AEROSOL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:13 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Specialty Tier |
25% | 25% | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
25% | 25% | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5 |
Specialty Tier |
25% | 25% | P |
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | 25% | None |
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2* |
Generic |
$12.00 | $30.00 | None |
ONDANSETRON HCL 24 MG TABLET |
2* |
Generic |
$12.00 | $30.00 | P Q:30 /30Days |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
3 |
Preferred Brand |
$47.00 | $117.50 | P |
ONDANSETRON HCL 8 MG TABLET |
2* |
Generic |
$12.00 | $30.00 | P Q:120 /30Days |
Ondansetron Hydrochloride 4mg/1 |
2* |
Generic |
$12.00 | $30.00 | P Q:90 /30Days |
ONDANSETRON ODT 4MG TABLET (30 CT) |
2* |
Generic |
$12.00 | $30.00 | P Q:90 /30Days |
ONDANSETRON ODT 8MG (10 CT) |
2* |
Generic |
$12.00 | $30.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONEXTON GEL PUMP |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ONFI 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ONFI 20 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days |
ONMEL 200 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
ONZETRA XSAIL 11 MG |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:16 /30Days |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ORACEA CAPSULES 40MG 30 BOT |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORALAIR 300 IR SUBLINGUAL TAB |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P |
ORAP 1MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ORAP 2MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ORAPRED ODT 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ORAPRED ODT 15 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ORAPRED ODT 30 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:90 /30Days |
ORENITRAM ER 0.25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | 25% | P |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
Orphenadrine 30 mg/ml vial |
2* |
Generic |
$12.00 | $30.00 | None |
Orphenadrine Citrate 100mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2* |
Generic |
$12.00 | $30.00 | None |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$12.00 | $30.00 | None |
ORTHO TRI CYCLEN Lo 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
OSMOPREP TABLET 1.5GM |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
OXACILLIN 10 GM VIAL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
Oxacillin 2 gm add-vantage vl |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | 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 |
$100.00 | $250.00 | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
5 |
Specialty Tier |
25% | 25% | None |
oxandrolone 10mg/1 60 TABLET BOTTLE |
5 |
Specialty Tier |
25% | 25% | None |
OXANDROLONE 2.5MG TABLETS |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
OXAPROZIN 600MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
oxazepam 10 mg capsule |
2* |
Generic |
$12.00 | $30.00 | None |
Oxazepam 15mg/1 |
2* |
Generic |
$12.00 | $30.00 | None |
oxazepam 30 mg capsule |
2* |
Generic |
$12.00 | $30.00 | None |
OXCARBAZEPINE 150MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2* |
Generic |
$12.00 | $30.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
2* |
Generic |
$12.00 | $30.00 | 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* |
Generic |
$12.00 | $30.00 | None |
OXICONAZOLE NITRATE 1% CREAM [Oxistat] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OXISTAT 1% CREAM |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S |
OXISTAT 1% LOTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S |
OXSORALEN-ULTRA 10MG CAP |
5 |
Specialty Tier |
25% | 25% | None |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OXTELLAR XR 600 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
OXYBUTYNIN 5MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R |
2* |
Generic |
$12.00 | $30.00 | Q:60 /30Days |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
2* |
Generic |
$12.00 | $30.00 | Q:30 /30Days |
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 |
2* |
Generic |
$12.00 | $30.00 | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
2* |
Generic |
$12.00 | $30.00 | Q:60 /30Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HCL 100 MG/5 ML SOLN |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HCL 30MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HCL 5 MG CAPSULE |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HCL 5 MG/5 ML Solution |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HCL 5MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HCL ER 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OXYCODONE HCL ER 15 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 20 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OXYCODONE HCL ER 30 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OXYCODONE HCL ER 40 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OXYCODONE HCL ER 60 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OXYCODONE HCL ER 80 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:120 /30Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
2* |
Generic |
$12.00 | $30.00 | None |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
2* |
Generic |
$12.00 | $30.00 | None |
Oxycodone-Acetaminophen 5-325/5 |
2* |
Generic |
$12.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2* |
Generic |
$12.00 | $30.00 | None |
OXYCODONE-IBUPROFEN 5-400 TAB |
2* |
Generic |
$12.00 | $30.00 | None |
OxyContin 10mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OxyContin 15mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OxyContin 20mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OxyContin 30mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OxyContin 40mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OxyContin 60mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:90 /30Days |
OxyContin 80mg/1 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:120 /30Days |
oxymorphone hcl er 10 mg tab |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
oxymorphone hcl er 20 mg tab |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxymorphone hcl er 30 mg tab |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
oxymorphone hcl er 40 mg tab |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
oxymorphone hcl er 5 mg tablet |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
OXYMORPHONE HYDROCHLORIDE 10MG TABLETS |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
OXYMORPHONE HYDROCHLORIDE 5MG TABLETS |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:8 /28Days |