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2017 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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Anthem Blue MedicareRx Standard (PDP) (S5596-017-0)
Tier 1 (241)
Tier 2 (844)
Tier 3 (613)
Tier 4 (841)
Tier 5 (562)
Tier 6 (60)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2017 Medicare Part D Plan Formulary Information
Anthem Blue MedicareRx Standard (PDP) (S5596-017-0)
Benefit Details           
The Anthem Blue MedicareRx Standard (PDP) (S5596-017-0)
Formulary Drugs Starting with the Letter O

in CMS PDP Region 15 which includes: IN KY
Plan Monthly Premium: $65.00 Deductible: $400 Qualifies for LIS: No
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   3 Preferred Brand $32.00N/ANone
OCTREOTIDE 1,000 mcg/ml vial   5 Specialty Tier 25%N/AP
OCTREOTIDE ACETATE 100 mcg/ml amp   4 Non-Preferred Drug 40%N/AP
OCTREOTIDE ACETATE 200 mcg/ml vl   4 Non-Preferred Drug 40%N/AP
OCTREOTIDE ACETATE 50 mcg/ml amp   4 Non-Preferred Drug 40%N/AP
OCTREOTIDE ACETATE 500 mcg/ml amp   4 Non-Preferred Drug 40%N/AP
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT   2 Generic $5.00N/ANone
ODEFSEY TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
ODOMZO 200 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
OFEV 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OFLOXACIN 0.3 % DRP   1* Preferred Generic $1.00N/ANone
OFLOXACIN 0.3% EAR DROPS   2 Generic $5.00N/ANone
OGESTREL TABLET 0.05MG/0.5MG   3 Preferred Brand $32.00N/ANone
OLANZAPINE 10 MG TABLET [Zyprexa]   3 Preferred Brand $32.00N/AQ:60
/30Days
OLANZAPINE 10 MG VIAL [Zyprexa]   4 Non-Preferred Drug 40%N/AQ:60
/30Days
OLANZAPINE 15 MG TABLET [Zyprexa]   3 Preferred Brand $32.00N/AQ:40
/30Days
OLANZAPINE 2.5 MG TABLET [Zyprexa]   2 Generic $5.00N/AQ:240
/30Days
OLANZAPINE 20 MG TABLET [Zyprexa]   3 Preferred Brand $32.00N/AQ:30
/30Days
OLANZAPINE 5 MG TABLET [Zyprexa]   3 Preferred Brand $32.00N/AQ:120
/30Days
OLANZAPINE 7.5 MG TABLET [Zyprexa]   2 Generic $5.00N/AQ:80
/30Days
OLANZAPINE ODT 10 MG TABLET [Zyprexa]   4 Non-Preferred Drug 40%N/AQ:60
/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 Drug 40%N/AQ:40
/30Days
OLANZAPINE ODT 20 MG TABLET [Zyprexa]   4 Non-Preferred Drug 40%N/AQ:30
/30Days
OLANZAPINE ODT 5 MG TABLET [Zyprexa]   3 Preferred Brand $32.00N/AQ:120
/30Days
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar]   4 Non-Preferred Drug 40%N/AQ:30
/30Days
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar]   4 Non-Preferred Drug 40%N/AQ:30
/30Days
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar]   4 Non-Preferred Drug 40%N/AQ:60
/30Days
OLMESARTAN-HCTZ 20-12.5 MG TAB   4 Non-Preferred Drug 40%N/AQ:30
/30Days
OLMESARTAN-HCTZ 40-12.5 MG TAB   4 Non-Preferred Drug 40%N/AQ:30
/30Days
OLMESARTAN-HCTZ 40-25 MG TAB   4 Non-Preferred Drug 40%N/AQ:30
/30Days
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR]   3 Preferred Brand $32.00N/AQ:30
/30Days
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR]   3 Preferred Brand $32.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR]   3 Preferred Brand $32.00N/AQ:30
/30Days
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR]   3 Preferred Brand $32.00N/AQ:30
/30Days
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR]   3 Preferred Brand $32.00N/AQ:30
/30Days
Olopatadine 2 MG/ML Ophthalmic Solution   3 Preferred Brand $32.00N/ANone
OLYSIO 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza]   3 Preferred Brand $32.00N/AP
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT)   2 Generic $5.00N/AQ:30
/30Days
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE   2 Generic $5.00N/AQ:30
/30Days
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG   2 Generic $5.00N/AQ:30
/30Days
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM   5 Specialty Tier 25%N/AP
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG   5 Specialty Tier 25%N/AP
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL   4 Non-Preferred Drug 40%N/ANone
ONDANSETRON 4 MG/2 ML ISECURE   4 Non-Preferred Drug 40%N/ANone
ONDANSETRON HCL 24 MG TABLET   4 Non-Preferred Drug 40%N/AP Q:30
/30Days
ONDANSETRON HCL 4 MG TABLET   2 Generic $5.00N/AP Q:90
/30Days
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL   2 Generic $5.00N/AP Q:450
/30Days
ONDANSETRON HCL 8 MG TABLET   2 Generic $5.00N/AP Q:90
/30Days
ONDANSETRON ODT 4MG TABLET (30 CT)   2 Generic $5.00N/AP Q:90
/30Days
ONDANSETRON ODT 8MG (10 CT)   2 Generic $5.00N/AP Q:90
/30Days
ONFI 10 MG TABLET   4 Non-Preferred Drug 40%N/AP Q:120
/30Days
ONFI 2.5 MG/ML SUSPENSION   4 Non-Preferred Drug 40%N/AP Q:480
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ONFI 20 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
OPDIVO 40 MG/4 ML VIAL   5 Specialty Tier 25%N/AP
ORENCIA 125 MG/ML SYRINGE   5 Specialty Tier 25%N/AP Q:4
/28Days
ORENCIA 250MG VIAL   5 Specialty Tier 25%N/AP
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS   5 Specialty Tier 25%N/AP Q:2
/28Days
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS   5 Specialty Tier 25%N/AP Q:3
/28Days
ORENCIA CLICKJECT 125 MG/ML   5 Specialty Tier 25%N/AP Q:4
/28Days
ORFADIN 10 MG CAPSULE   5 Specialty Tier 25%N/AP
ORFADIN 2 MG CAPSULE   5 Specialty Tier 25%N/AP
ORFADIN 4 MG/ML SUSPENSION   5 Specialty Tier 25%N/AP
ORFADIN 5 MG CAPSULE   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ORKAMBI 100 MG-125 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
ORKAMBI 200 MG-125 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $32.00N/ANone
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu]   3 Preferred Brand $32.00N/ANone
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu]   3 Preferred Brand $32.00N/ANone
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu]   3 Preferred Brand $32.00N/ANone
OXACILLIN 10 GM VIAL   5 Specialty Tier 25%N/ANone
OXACILLIN 1GM/50ML INJ   4 Non-Preferred Drug 40%N/ANone
OXACILLIN 2GM/50ML INJ   5 Specialty Tier 25%N/ANone
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION   4 Non-Preferred Drug 40%N/ANone
oxandrolone 10mg/1 60 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OXANDROLONE 2.5MG TABLETS   3 Preferred Brand $32.00N/AP Q:120
/30Days
OXCARBAZEPINE 150MG TABLET   3 Preferred Brand $32.00N/ANone
OXCARBAZEPINE 300 MG/5 ML SUSP   4 Non-Preferred Drug 40%N/ANone
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT   3 Preferred Brand $32.00N/ANone
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT   3 Preferred Brand $32.00N/ANone
OXYBUTYNIN 5 MG/5 ML SYRUP   2 Generic $5.00N/AQ:600
/30Days
OXYBUTYNIN 5MG TABLET   2 Generic $5.00N/AQ:120
/30Days
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R   2 Generic $5.00N/AQ:60
/30Days
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE   2 Generic $5.00N/AQ:30
/30Days
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT)   2 Generic $5.00N/AQ:60
/30Days
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT)   3 Preferred Brand $32.00N/AQ:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT   3 Preferred Brand $32.00N/AQ:360
/30Days
OXYCODONE HCL 30MG TABLET   3 Preferred Brand $32.00N/AQ:180
/30Days
OXYCODONE HCL 5 MG CAPSULE   4 Non-Preferred Drug 40%N/AQ:360
/30Days
OXYCODONE HCL 5 MG/5 ML SOLN   3 Preferred Brand $32.00N/AQ:1800
/30Days
OXYCODONE HCL 5MG TABLET   3 Preferred Brand $32.00N/AQ:360
/30Days
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET   3 Preferred Brand $32.00N/AQ:360
/30Days
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE   3 Preferred Brand $32.00N/AQ:360
/30Days
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE   3 Preferred Brand $32.00N/AQ:180
/30Days
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL   3 Preferred Brand $32.00N/AQ:180
/30Days
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET   3 Preferred Brand $32.00N/AQ:360
/30Days
OXYCODONE-ASPIRIN 4.8355-325   3 Preferred Brand $32.00N/AQ:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OXYCODONE-IBUPROFEN 5-400 TAB   3 Preferred Brand $32.00N/AQ:28
/7Days

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Anthem Blue MedicareRx Standard (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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

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.







Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.