2017 Medicare Part D Plan Formulary Information |
Advantra Gold (PPO) (H1608-025-0)
Benefit Details
|
The Advantra Gold (PPO) (H1608-025-0) Formulary Drugs Starting with the Letter O in Caldwell County, NC: CMS MA Region 7 which includes: NC Plan Monthly Premium: $44.00 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 |
$5.00 | $15.00 | None |
OCTREOTIDE 1,000 mcg/ml vial |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACETATE 100 mcg/ml amp |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACETATE 200 mcg/ml vl |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACETATE 50 mcg/ml amp |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACETATE 500 mcg/ml amp |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | 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% | N/A | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OFLOXACIN 0.3% EAR DROPS |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Ofloxacin 300 mg tablet |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OFLOXACIN 400MG TABLET (100 CT) |
2 |
Generic |
$5.00 | $15.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2 |
Generic |
$5.00 | $15.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL [Zyprexa] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $141.00 | 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] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-50 MG |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
olanzapine-fluoxetine 3-25 mg |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-25 MG |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-50 MG |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Olopatadine 2 MG/ML Ophthalmic Solution |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days |
OMNARIS 50MCG SPRAY NON-AEROSOL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:13 /30Days |
OMNIPRED OPHTHALMIC SUSPENSION 1% 10 ML BOTPL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2 |
Generic |
$5.00 | $15.00 | None |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | P |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:900 /30Days |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | P |
ONDANSETRON ODT 4MG TABLET (30 CT) |
2 |
Generic |
$5.00 | $15.00 | P |
ONDANSETRON ODT 8MG (10 CT) |
2 |
Generic |
$5.00 | $15.00 | P |
ONFI 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ONFI 20 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ONGLYZA 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
ONGLYZA 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:112 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:112 /28Days |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$5.00 | $15.00 | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:170 /365Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:90 /365Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:90 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSMOPREP TABLET 1.5GM |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 12.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S |
OXACILLIN 10 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXACILLIN 2GM/50ML INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
oxandrolone 10mg/1 60 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OXANDROLONE 2.5MG TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:120 /30Days |
OXAPROZIN 600MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXCARBAZEPINE 150MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXICONAZOLE NITRATE 1% CREAM [Oxistat] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXISTAT 1% CREAM |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2 |
Generic |
$5.00 | $15.00 | Q:600 /30Days |
OXYBUTYNIN 5MG TABLET |
2 |
Generic |
$5.00 | $15.00 | Q:120 /30Days |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days |
OXYCODONE HCL 30MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:120 /30Days |
OXYCODONE HCL 5 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:5400 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 5MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:120 /30Days |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:8 /28Days |