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2017 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-164-0) Benefit Details
The First Health Part D Premier Plus (PDP) (S5768-164-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 5 which includes: DC DE MD Plan Monthly Premium: $125.70 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter O Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter O Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
OCELLA 3MG/0.03MG TABLET	2	Generic	$2.00	$6.00	None
OCTREOTIDE 1,000 mcg/ml vial	4	Non-Preferred Drug	50%	50%	P
OCTREOTIDE ACETATE 100 mcg/ml amp	4	Non-Preferred Drug	50%	50%	P
OCTREOTIDE ACETATE 200 mcg/ml vl	4	Non-Preferred Drug	50%	50%	P
OCTREOTIDE ACETATE 50 mcg/ml amp	4	Non-Preferred Drug	50%	50%	P
OCTREOTIDE ACETATE 500 mcg/ml amp	4	Non-Preferred Drug	50%	50%	P
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT	3	Preferred Brand	$34.00	$102.00	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	$34.00	$102.00	None
OFLOXACIN 0.3% EAR DROPS	4	Non-Preferred Drug	50%	50%	None
Ofloxacin 300 mg tablet	4	Non-Preferred Drug	50%	50%	None
OFLOXACIN 400MG TABLET (100 CT)	2	Generic	$2.00	$6.00	None
OGESTREL TABLET 0.05MG/0.5MG	2	Generic	$2.00	$6.00	None
OLANZAPINE 10 MG TABLET [Zyprexa]	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
OLANZAPINE 10 MG VIAL [Zyprexa]	4	Non-Preferred Drug	50%	50%	None
OLANZAPINE 15 MG TABLET [Zyprexa]	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
OLANZAPINE 2.5 MG TABLET [Zyprexa]	3	Preferred Brand	$34.00	$102.00	Q:60 /30Days
OLANZAPINE 20 MG TABLET [Zyprexa]	3	Preferred Brand	$34.00	$102.00	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	$34.00	$102.00	Q:30 /30Days
OLANZAPINE 7.5 MG TABLET [Zyprexa]	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
OLANZAPINE ODT 10 MG TABLET [Zyprexa]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE ODT 15 MG TABLET [Zyprexa]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE ODT 20 MG TABLET [Zyprexa]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE ODT 5 MG TABLET [Zyprexa]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE-FLUOXETINE 12-25 MG	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE-FLUOXETINE 12-50 MG	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
olanzapine-fluoxetine 3-25 mg	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE-FLUOXETINE 6-25 MG	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLANZAPINE-FLUOXETINE 6-50 MG	4	Non-Preferred Drug	50%	50%	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	50%	50%	Q:30 /30Days
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLMESARTAN-HCTZ 20-12.5 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLMESARTAN-HCTZ 40-12.5 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
OLMESARTAN-HCTZ 40-25 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR]	4	Non-Preferred Drug	50%	50%	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	50%	50%	None
OLOPATADINE 665 MCG NASAL SPRY	4	Non-Preferred Drug	50%	50%	Q:31 /30Days
OLOPATADINE HCL 0.1% EYE DROPS	4	Non-Preferred Drug	50%	50%	None
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza]	4	Non-Preferred Drug	50%	50%	Q:120 /30Days
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT)	1	Preferred Generic	$1.00	$3.00	Q:30 /30Days
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE	1	Preferred Generic	$1.00	$3.00	None
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG	1	Preferred Generic	$1.00	$3.00	Q:60 /30Days
OMNARIS 50MCG SPRAY NON-AEROSOL	4	Non-Preferred Drug	50%	50%	Q:13 /30Days
OMNIPRED OPHTHALMIC SUSPENSION 1% 10 ML BOTPL	4	Non-Preferred Drug	50%	50%	None
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL	2	Generic	$2.00	$6.00	None
ONDANSETRON HCL 24 MG TABLET	2	Generic	$2.00	$6.00	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	$2.00	$6.00	P
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL	3	Preferred Brand	$34.00	$102.00	P Q:900 /30Days
ONDANSETRON HCL 8 MG TABLET	2	Generic	$2.00	$6.00	P
ONDANSETRON ODT 4MG TABLET (30 CT)	2	Generic	$2.00	$6.00	P
ONDANSETRON ODT 8MG (10 CT)	2	Generic	$2.00	$6.00	P
ONFI 10 MG TABLET	4	Non-Preferred Drug	50%	50%	None
ONFI 2.5 MG/ML SUSPENSION	4	Non-Preferred Drug	50%	50%	None
ONFI 20 MG TABLET	4	Non-Preferred Drug	50%	50%	None
ONGLYZA 2.5 MG TABLET	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
ONGLYZA 5 MG TABLET	4	Non-Preferred Drug	50%	50%	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	$2.00	$6.00	None
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu]	4	Non-Preferred Drug	50%	50%	Q:170 /365Days
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu]	4	Non-Preferred Drug	50%	50%	Q:90 /365Days
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu]	4	Non-Preferred Drug	50%	50%	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	50%	50%	S
OTREXUP 10 MG/0.4 ML AUTO-INJ	4	Non-Preferred Drug	50%	50%	S
OTREXUP 12.5 MG/0.4 ML AUTOINJ	4	Non-Preferred Drug	50%	50%	S
OTREXUP 15 MG/0.4 ML AUTO-INJ	4	Non-Preferred Drug	50%	50%	S
OTREXUP 17.5 MG/0.4 ML AUTOINJ	4	Non-Preferred Drug	50%	50%	S
OTREXUP 20 MG/0.4 ML AUTO-INJ	4	Non-Preferred Drug	50%	50%	S
OTREXUP 22.5 MG/0.4 ML AUTOINJ	4	Non-Preferred Drug	50%	50%	S
OTREXUP 25 MG/0.4 ML AUTO-INJ	4	Non-Preferred Drug	50%	50%	S
OXACILLIN 10 GM VIAL	4	Non-Preferred Drug	50%	50%	None
OXACILLIN 1GM/50ML INJ	4	Non-Preferred Drug	50%	50%	None
OXACILLIN 2GM/50ML INJ	4	Non-Preferred Drug	50%	50%	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	50%	50%	None
oxandrolone 10mg/1 60 TABLET BOTTLE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
OXANDROLONE 2.5MG TABLETS	3	Preferred Brand	$34.00	$102.00	P Q:120 /30Days
OXAPROZIN 600MG TABLET	4	Non-Preferred Drug	50%	50%	None
OXCARBAZEPINE 150MG TABLET	3	Preferred Brand	$34.00	$102.00	None
OXCARBAZEPINE 300 MG/5 ML SUSP	4	Non-Preferred Drug	50%	50%	None
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT	3	Preferred Brand	$34.00	$102.00	None
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT	3	Preferred Brand	$34.00	$102.00	None
OXICONAZOLE NITRATE 1% CREAM [Oxistat]	4	Non-Preferred Drug	50%	50%	None
OXISTAT 1% CREAM	4	Non-Preferred Drug	50%	50%	None
OXISTAT 1% LOTION	4	Non-Preferred Drug	50%	50%	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	$2.00	$6.00	Q:600 /30Days
OXYBUTYNIN 5MG TABLET	2	Generic	$2.00	$6.00	Q:120 /30Days
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R	3	Preferred Brand	$34.00	$102.00	Q:60 /30Days
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT)	3	Preferred Brand	$34.00	$102.00	Q:60 /30Days
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT)	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE HCL 100 MG/5 ML SOLN	4	Non-Preferred Drug	50%	50%	Q:180 /30Days
OXYCODONE HCL 30MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:120 /30Days
OXYCODONE HCL 5 MG CAPSULE	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE HCL 5 MG/5 ML SOLN	3	Preferred Brand	$34.00	$102.00	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	$34.00	$102.00	Q:180 /30Days
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE-ASPIRIN 4.8355-325	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
OXYCODONE-IBUPROFEN 5-400 TAB	3	Preferred Brand	$34.00	$102.00	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	50%	50%	S Q:8 /28Days

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D First Health Part D Premier Plus (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.