2017 Medicare Part D Plan Formulary Information |
Humana Enhanced (PDP) (S5884-004-0)
Benefit Details
|
The Humana Enhanced (PDP) (S5884-004-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 5 which includes: DC DE MD Plan Monthly Premium: $66.20 Deductible: $0 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 |
4 |
Non-Preferred Drug |
44% | 44% | None |
OCTREOTIDE 1,000 mcg/ml vial |
4 |
Non-Preferred Drug |
44% | 44% | P |
OCTREOTIDE ACETATE 100 mcg/ml amp |
4 |
Non-Preferred Drug |
44% | 44% | P |
OCTREOTIDE ACETATE 200 mcg/ml vl |
4 |
Non-Preferred Drug |
44% | 44% | P |
OCTREOTIDE ACETATE 50 mcg/ml amp |
4 |
Non-Preferred Drug |
44% | 44% | P |
OCTREOTIDE ACETATE 500 mcg/ml amp |
4 |
Non-Preferred Drug |
44% | 44% | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
3 |
Preferred Brand |
$42.00 | $116.00 | 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 |
2 |
Generic |
$7.00 | $0.00 | None |
OFLOXACIN 0.3% EAR DROPS |
3 |
Preferred Brand |
$42.00 | $116.00 | None |
Ofloxacin 300 mg tablet |
2 |
Generic |
$7.00 | $0.00 | None |
OFLOXACIN 400MG TABLET (100 CT) |
2 |
Generic |
$7.00 | $0.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
4 |
Non-Preferred Drug |
44% | 44% | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL [Zyprexa] |
3 |
Preferred Brand |
$42.00 | $116.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /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 |
$42.00 | $116.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
44% | 44% | Q:60 /30Days |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
44% | 44% | Q:60 /30Days |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-50 MG |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
olanzapine-fluoxetine 3-25 mg |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-25 MG |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-50 MG |
4 |
Non-Preferred Drug |
44% | 44% | 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 |
44% | 44% | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLOPATADINE HCL 0.1% EYE DROPS |
4 |
Non-Preferred Drug |
44% | 44% | S |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
4 |
Non-Preferred Drug |
44% | 44% | Q:120 /30Days |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) |
2 |
Generic |
$7.00 | $0.00 | Q:60 /30Days |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE |
2 |
Generic |
$7.00 | $0.00 | Q:60 /30Days |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG |
2 |
Generic |
$7.00 | $0.00 | Q:60 /30Days |
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 |
$7.00 | $0.00 | None |
ONDANSETRON 4 MG/2 ML ISECURE |
2 |
Generic |
$7.00 | $0.00 | None |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | P Q:90 /30Days |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL |
4 |
Non-Preferred Drug |
44% | 44% | P Q:450 /30Days |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$7.00 | $0.00 | P Q:90 /30Days |
ONDANSETRON ODT 4MG TABLET (30 CT) |
2 |
Generic |
$7.00 | $0.00 | P Q:90 /30Days |
ONDANSETRON ODT 8MG (10 CT) |
2 |
Generic |
$7.00 | $0.00 | P Q:90 /30Days |
ONFI 10 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | P Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Drug |
44% | 44% | P Q:480 /30Days |
ONFI 20 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | P Q:60 /30Days |
ONGLYZA 2.5 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OPANA ER 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA ER 15 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OPANA ER 20 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OPANA ER 30 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OPANA ER 40 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OPANA ER 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OPANA ER 7.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
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 |
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 |
33% | N/A | P Q:112 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:112 /28Days |
Orphenadrine Citrate 100mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
44% | 44% | None |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
44% | 44% | None |
Ortho Cyclen 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
44% | 44% | None |
Ortho Micronor 0.35mg/1 6 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK |
4 |
Non-Preferred Drug |
44% | 44% | None |
Ortho Novum 135 6 DIALPACK in 1 CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Drug |
44% | 44% | None |
ORTHO TRI CYCLEN Lo 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Drug |
44% | 44% | None |
Ortho-Novum 777 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK |
4 |
Non-Preferred Drug |
44% | 44% | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
4 |
Non-Preferred Drug |
44% | 44% | Q:112 /365Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
4 |
Non-Preferred Drug |
44% | 44% | Q:56 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
4 |
Non-Preferred Drug |
44% | 44% | Q:56 /365Days |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days |
OVCON 35 72 CARTON in 1 CASE / 3 CELLO PACK per CARTON / 1 BLISTER PACK in 1 CELLO PACK / 1 KIT i |
4 |
Non-Preferred Drug |
44% | 44% | None |
OXACILLIN 10 GM VIAL |
4 |
Non-Preferred Drug |
44% | 44% | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Drug |
44% | 44% | None |
OXACILLIN 2GM/50ML INJ |
5 |
Specialty Tier |
33% | N/A | 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 |
44% | 44% | None |
oxandrolone 10mg/1 60 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OXANDROLONE 2.5MG TABLETS |
3 |
Preferred Brand |
$42.00 | $116.00 | P Q:120 /30Days |
OXAPROZIN 600MG TABLET |
4 |
Non-Preferred Drug |
44% | 44% | None |
oxazepam 10 mg capsule |
4 |
Non-Preferred Drug |
44% | 44% | None |
Oxazepam 15mg/1 |
4 |
Non-Preferred Drug |
44% | 44% | None |
oxazepam 30 mg capsule |
4 |
Non-Preferred Drug |
44% | 44% | None |
OXCARBAZEPINE 150MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
44% | 44% | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT |
3 |
Preferred Brand |
$42.00 | $116.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT |
3 |
Preferred Brand |
$42.00 | $116.00 | 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 |
$7.00 | $0.00 | None |
OXYBUTYNIN 5MG TABLET |
2 |
Generic |
$7.00 | $0.00 | None |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:60 /30Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
44% | 44% | Q:270 /30Days |
OXYCODONE HCL 30MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG CAPSULE |
4 |
Non-Preferred Drug |
44% | 44% | Q:360 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN |
3 |
Preferred Brand |
$42.00 | $116.00 | 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 |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
3 |
Preferred Brand |
$42.00 | $116.00 | Q:360 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
4 |
Non-Preferred Drug |
44% | 44% | Q:360 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
4 |
Non-Preferred Drug |
44% | 44% | Q:240 /30Days |