2018 Medicare Part D Plan Formulary Information |
Blue Shield 65 Plus Choice Plan (HMO) (H0504-021-0)
Benefit Details
|
The Blue Shield 65 Plus Choice Plan (HMO) (H0504-021-0) Formulary Drugs Starting with the Letter O in Orange County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $0.00 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 |
OCALIVA 10 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OCALIVA 5 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OCELLA 3MG/0.03MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
OCTAGAM 10% VIAL |
6 |
Specialty Tier |
33% | N/A | P |
OCTAGAM 5% VIAL |
6 |
Specialty Tier |
33% | N/A | P |
OCTREOTIDE 1,000 MCG/ML VIAL |
6 |
Specialty Tier |
33% | N/A | P |
OCTREOTIDE ACET 0.05 MG/ML VL |
5 |
Injectable Drugs |
31% | N/A | P |
OCTREOTIDE ACET 100 MCG/ML VL |
5 |
Injectable Drugs |
31% | N/A | P |
OCTREOTIDE ACET 200 MCG/ML VL |
5 |
Injectable Drugs |
31% | N/A | P |
OCTREOTIDE ACET 500 MCG/ML VL |
6 |
Specialty Tier |
33% | 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 |
2 |
Generic |
$10.00 | N/A | None |
ODEFSEY TABLET |
6 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
ODOMZO 200 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OFEV 100 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OFEV 150 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
2 |
Generic |
$10.00 | N/A | None |
OFLOXACIN 0.3% EAR DROPS |
2 |
Generic |
$10.00 | N/A | None |
OFLOXACIN 300 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
OFLOXACIN 400 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
OGESTREL TABLET 0.05MG/0.5MG |
2 |
Generic |
$10.00 | N/A | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 10 MG VIAL |
5 |
Injectable Drugs |
31% | N/A | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$10.00 | N/A | None |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$10.00 | N/A | None |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$10.00 | N/A | None |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$10.00 | N/A | None |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$10.00 | N/A | None |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P 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] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:90 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:30 /30Days |
Olopatadine 2 MG/ML Ophthalmic Solution |
3 |
Preferred Brand |
$40.00 | N/A | Q:3 /30Days |
OLOPATADINE 665 MCG NASAL SPRY |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2 |
Generic |
$10.00 | N/A | Q:10 /30Days |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:120 /30Days |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$3.00 | N/A | None |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
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 |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$3.00 | N/A | None |
ONDANSETRON 4 MG/2 ML ISECURE |
5 |
Injectable Drugs |
31% | N/A | P |
ONDANSETRON 4 MG/5 ML SOLUTION |
2 |
Generic |
$10.00 | N/A | P Q:450 /30Days |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$10.00 | N/A | P Q:15 /30Days |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$10.00 | N/A | P Q:90 /30Days |
ONDANSETRON HCL 4 MG/2 ML VIAL |
5 |
Injectable Drugs |
31% | N/A | P |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$10.00 | N/A | P Q:90 /30Days |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$10.00 | N/A | P Q:90 /30Days |
ONDANSETRON ODT 8 MG TABLET |
2 |
Generic |
$10.00 | N/A | P Q:90 /30Days |
ONFI 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S Q:60 /30Days |
OPDIVO 100 MG/10 ML VIAL |
6 |
Specialty Tier |
33% | N/A | P |
OPDIVO 40 MG/4 ML VIAL |
6 |
Specialty Tier |
33% | N/A | P |
OPSUMIT 10 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ORBACTIV 400 MG VIAL |
6 |
Specialty Tier |
33% | N/A | P Q:9 /30Days |
ORFADIN 10 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
ORFADIN 2 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
ORFADIN 20 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
ORFADIN 4 MG/ML SUSPENSION |
6 |
Specialty Tier |
33% | N/A | P |
ORFADIN 5 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
ORKAMBI 100 MG-125 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORKAMBI 200 MG-125 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
ORPHENADRINE ER 100 MG TABLET [Norflex] |
2 |
Generic |
$10.00 | N/A | P |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$10.00 | N/A | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
3 |
Preferred Brand |
$40.00 | N/A | Q:1080 /365Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
3 |
Preferred Brand |
$40.00 | N/A | Q:56 /180Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
3 |
Preferred Brand |
$40.00 | N/A | Q:42 /180Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
3 |
Preferred Brand |
$40.00 | N/A | Q:28 /180Days |
OXACILLIN 1 GM VIAL |
5 |
Injectable Drugs |
31% | N/A | None |
Oxacillin 100 MG/ML Injectable Solution |
5 |
Injectable Drugs |
31% | N/A | None |
OXACILLIN 1GM/50ML INJ |
5 |
Injectable Drugs |
31% | N/A | None |
Oxacillin 2000 MG Injection |
5 |
Injectable Drugs |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN 2GM/50ML INJ |
5 |
Injectable Drugs |
31% | N/A | None |
OXALIPLATIN 100 MG VIAL |
5 |
Injectable Drugs |
31% | N/A | P |
OXALIPLATIN 100 MG/20 ML VIAL |
5 |
Injectable Drugs |
31% | N/A | P |
OXANDROLONE 10 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
OXANDROLONE 2.5 MG TABLET |
3 |
Preferred Brand |
$40.00 | N/A | P |
OXAPROZIN 600 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
OXAZEPAM 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:360 /30Days |
OXAZEPAM 15 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:240 /30Days |
OXAZEPAM 30 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:120 /30Days |
OXCARBAZEPINE 150 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
OXCARBAZEPINE 300 MG TABLET |
2 |
Generic |
$10.00 | 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 |
3 |
Preferred Brand |
$40.00 | N/A | P |
OXCARBAZEPINE 600 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:30 /30Days |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:30 /30Days |
OXTELLAR XR 600 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:120 /30Days |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2 |
Generic |
$10.00 | N/A | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
OXYBUTYNIN CL ER 10 MG TABLET |
2 |
Generic |
$10.00 | N/A | Q:90 /30Days |
OXYBUTYNIN CL ER 15 MG TABLET |
2 |
Generic |
$10.00 | N/A | Q:60 /30Days |
OXYBUTYNIN CL ER 5 MG TABLET |
2 |
Generic |
$10.00 | N/A | Q:180 /30Days |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2 |
Generic |
$10.00 | N/A | Q:168 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2 |
Generic |
$10.00 | N/A | Q:112 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2 |
Generic |
$10.00 | N/A | Q:84 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2 |
Generic |
$10.00 | N/A | Q:56 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2 |
Generic |
$10.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2 |
Generic |
$10.00 | N/A | Q:28 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
4 |
Non-Preferred Brand |
$95.00 | N/A | Q:168 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2 |
Generic |
$10.00 | N/A | Q:168 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
3 |
Preferred Brand |
$40.00 | N/A | Q:840 /30Days |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 80 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$95.00 | N/A | P Q:60 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325 |
2 |
Generic |
$10.00 | N/A | Q:84 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
2 |
Generic |
$10.00 | N/A | Q:168 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
3 |
Preferred Brand |
$40.00 | N/A | Q:168 /30Days |