2017 Medicare Part D Plan Formulary Information |
Gundersen Senior Preferred Elite (w/Rx) (HMO) (H5262-001-0)
Benefit Details
|
The Gundersen Senior Preferred Elite (w/Rx) (HMO) (H5262-001-0) Formulary Drugs Starting with the Letter O in Vernon County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $171.90 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 |
OCALIVA 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OCELLA 3MG/0.03MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OCTREOTIDE 1,000 mcg/ml vial |
4 |
Non-Preferred Drug |
40% | N/A | P |
OCTREOTIDE ACETATE 100 mcg/ml amp |
2 |
Generic |
$15.00 | N/A | P |
OCTREOTIDE ACETATE 200 mcg/ml vl |
2 |
Generic |
$15.00 | N/A | P |
OCTREOTIDE ACETATE 50 mcg/ml amp |
2 |
Generic |
$15.00 | N/A | P |
OCTREOTIDE ACETATE 500 mcg/ml amp |
4 |
Non-Preferred Drug |
40% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Preferred Generic |
$3.00 | N/A | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
33% | N/A | None |
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 |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
1 |
Preferred Generic |
$3.00 | N/A | None |
OFLOXACIN 0.3% EAR DROPS |
1 |
Preferred Generic |
$3.00 | N/A | None |
Ofloxacin 300 mg tablet |
4 |
Non-Preferred Drug |
40% | N/A | None |
OFLOXACIN 400MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
40% | N/A | None |
OGESTREL TABLET 0.05MG/0.5MG |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 10 MG VIAL [Zyprexa] |
4 |
Non-Preferred Drug |
40% | N/A | P |
OLANZAPINE 15 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLANZAPINE 20 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLANZAPINE 5 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
2 |
Generic |
$15.00 | N/A | Q:60 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
2 |
Generic |
$15.00 | N/A | Q:30 /30Days |
Olopatadine 2 MG/ML Ophthalmic Solution |
2 |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLOPATADINE HCL 0.1% EYE DROPS |
1 |
Preferred Generic |
$3.00 | N/A | None |
OLYSIO 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
1 |
Preferred Generic |
$3.00 | N/A | None |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$3.00 | N/A | None |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
1 |
Preferred Generic |
$3.00 | N/A | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Specialty Tier |
33% | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
33% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5 |
Specialty Tier |
33% | N/A | P |
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2 |
Generic |
$15.00 | N/A | None |
ONDANSETRON 4 MG/2 ML ISECURE |
2 |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$15.00 | N/A | P |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$15.00 | N/A | P |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
2 |
Generic |
$15.00 | N/A | P |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$15.00 | N/A | P |
ONDANSETRON ODT 4MG TABLET (30 CT) |
2 |
Generic |
$15.00 | N/A | P |
ONDANSETRON ODT 8MG (10 CT) |
2 |
Generic |
$15.00 | N/A | P |
ONFI 10 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | Q:480 /30Days |
ONFI 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONMEL 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
OPANA ER 10 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OPANA ER 15 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OPANA ER 20 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OPANA ER 30 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OPANA ER 40 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OPANA ER 5 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OPANA ER 7.5 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /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 |
ORAP 1MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
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 Q:4 /28Days |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | P Q:3 /28Days |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | P Q:180 /30Days |
ORENITRAM ER 0.25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
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 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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:120 /30Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$3.00 | N/A | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2 |
Generic |
$15.00 | N/A | Q:60 /30Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2 |
Generic |
$15.00 | N/A | Q:60 /30Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2 |
Generic |
$15.00 | N/A | Q:60 /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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN 10 GM VIAL |
5 |
Specialty Tier |
33% | N/A | None |
OXACILLIN 1GM/50ML INJ |
2 |
Generic |
$15.00 | N/A | None |
OXACILLIN 2GM/50ML INJ |
4 |
Non-Preferred Drug |
40% | N/A | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION |
4 |
Non-Preferred Drug |
40% | N/A | P |
oxandrolone 10mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Drug |
40% | N/A | P Q:60 /30Days |
OXANDROLONE 2.5MG TABLETS |
4 |
Non-Preferred Drug |
40% | N/A | P Q:120 /30Days |
OXAPROZIN 600MG TABLET |
2 |
Generic |
$15.00 | N/A | None |
oxazepam 10 mg capsule |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
Oxazepam 15mg/1 |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
oxazepam 30 mg capsule |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
OXCARBAZEPINE 150MG TABLET |
2 |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2 |
Generic |
$15.00 | N/A | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
2 |
Generic |
$15.00 | N/A | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
2 |
Generic |
$15.00 | N/A | None |
OXICONAZOLE NITRATE 1% CREAM [Oxistat] |
4 |
Non-Preferred Drug |
40% | N/A | None |
OXISTAT 1% CREAM |
4 |
Non-Preferred Drug |
40% | N/A | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Drug |
40% | N/A | None |
OXSORALEN-ULTRA 10MG CAP |
5 |
Specialty Tier |
33% | N/A | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
1 |
Preferred Generic |
$3.00 | N/A | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R |
1 |
Preferred Generic |
$3.00 | N/A | None |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
1 |
Preferred Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
1 |
Preferred Generic |
$3.00 | N/A | None |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
1 |
Preferred Generic |
$3.00 | N/A | Q:360 /30Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
2 |
Generic |
$15.00 | N/A | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN |
2 |
Generic |
$15.00 | N/A | Q:360 /30Days |
OXYCODONE HCL 30MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | Q:480 /30Days |
OXYCODONE HCL 5 MG CAPSULE |
2 |
Generic |
$15.00 | N/A | Q:480 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN |
2 |
Generic |
$15.00 | N/A | Q:7200 /30Days |
OXYCODONE HCL 5MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | Q:480 /30Days |
OXYCODONE HCL ER 10 MG TABLET |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
OXYCODONE HCL ER 15 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OXYCODONE HCL ER 20 MG TABLET |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 30 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OXYCODONE HCL ER 40 MG TABLET |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
OXYCODONE HCL ER 60 MG TABLET |
4 |
Non-Preferred Drug |
40% | N/A | Q:120 /30Days |
OXYCODONE HCL ER 80 MG TABLET |
2 |
Generic |
$15.00 | N/A | Q:180 /30Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
2 |
Generic |
$15.00 | N/A | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | N/A | Q:480 /30Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | N/A | Q:480 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
1 |
Preferred Generic |
$3.00 | N/A | Q:480 /30Days |
Oxycodone-Acetaminophen 5-325/5 |
2 |
Generic |
$15.00 | N/A | Q:1860 /30Days |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2 |
Generic |
$15.00 | N/A | Q:360 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
2 |
Generic |
$15.00 | N/A | 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 |
2 |
Generic |
$15.00 | N/A | Q:120 /30Days |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
OxyContin 80mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:180 /30Days |