2018 Medicare Part D Plan Formulary Information |
Allwell Dual Medicare Essentials (HMO SNP) (H1436-006-0)
Benefit Details
|
The Allwell Dual Medicare Essentials (HMO SNP) (H1436-006-0) Formulary Drugs Starting with the Letter O in Colleton County, SC: CMS MA Region 8 which includes: SC Plan Monthly Premium: $0.00 Deductible: $140 |
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 |
30% | N/A | P |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
OCELLA 3MG/0.03MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
30% | N/A | P |
OCTREOTIDE ACET 0.05 MG/ML VL |
1* |
Preferred Generic |
$0.00 | N/A | None |
OCTREOTIDE ACET 100 MCG/ML VL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OCTREOTIDE ACET 200 MCG/ML VL |
1* |
Preferred Generic |
$0.00 | N/A | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
3 |
Preferred Brand |
$47.00 | N/A | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
30% | N/A | None |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
OFLOXACIN 0.3 % DRP |
2 |
Generic |
$12.00 | N/A | None |
OFLOXACIN 0.3% EAR DROPS |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | N/A | None |
OLANZAPINE 10 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | N/A | None |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | N/A | None |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | N/A | None |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | N/A | None |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Olopatadine 2 MG/ML Ophthalmic Solution |
3 |
Preferred Brand |
$47.00 | N/A | None |
OLOPATADINE 665 MCG NASAL SPRY |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$0.00 | N/A | None |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$0.00 | N/A | None |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$0.00 | N/A | None |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] |
2 |
Generic |
$12.00 | N/A | None |
OMEPRAZOLE-BICARB 20-1,680 PKT PACKET [Zegerid] |
2 |
Generic |
$12.00 | N/A | S |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
30% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5 |
Specialty Tier |
30% | N/A | P |
ONDANSETRON 4 MG/2 ML ISECURE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ONDANSETRON 4 MG/5 ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 24 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
ONDANSETRON HCL 4 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
ONDANSETRON HCL 4 MG/2 ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ONDANSETRON HCL 8 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$12.00 | N/A | P |
ONDANSETRON ODT 8 MG TABLET |
2 |
Generic |
$12.00 | N/A | P |
ONFI 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ONFI 20 MG TABLET |
5 |
Specialty Tier |
30% | N/A | None |
ONGLYZA 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P Q:2 /1Days |
ONGLYZA 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPDIVO 100 MG/10 ML VIAL |
5 |
Specialty Tier |
30% | N/A | None |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
30% | N/A | None |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
ORBACTIV 400 MG VIAL |
5 |
Specialty Tier |
30% | N/A | None |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
30% | N/A | P |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
30% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
30% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
30% | N/A | P |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
30% | N/A | P |
ORFADIN 10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
ORFADIN 2 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORFADIN 20 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
ORFADIN 5 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$12.00 | N/A | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
2 |
Generic |
$12.00 | N/A | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2 |
Generic |
$12.00 | N/A | Q:4 /1Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2 |
Generic |
$12.00 | N/A | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2 |
Generic |
$12.00 | N/A | None |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
30% | N/A | P |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
OTREXUP 12.5 MG/0.4 ML AUTOINJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
3 |
Preferred Brand |
$47.00 | N/A | P |
OXALIPLATIN 100 MG VIAL |
5 |
Specialty Tier |
30% | N/A | None |
OXALIPLATIN 100 MG/20 ML VIAL |
2 |
Generic |
$12.00 | N/A | None |
OXANDROLONE 10 MG TABLET |
5 |
Specialty Tier |
30% | N/A | None |
OXANDROLONE 2.5 MG TABLET |
2 |
Generic |
$12.00 | N/A | None |
OXAPROZIN 600 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
OXAZEPAM 10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXAZEPAM 15 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXAZEPAM 30 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXCARBAZEPINE 150 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXCARBAZEPINE 300 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXCARBAZEPINE 600 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2 |
Generic |
$12.00 | N/A | None |
OXYBUTYNIN 5MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYBUTYNIN CL ER 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYBUTYNIN CL ER 15 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYBUTYNIN CL ER 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2 |
Generic |
$12.00 | N/A | None |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2 |
Generic |
$12.00 | N/A | None |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
3 |
Preferred Brand |
$47.00 | N/A | Q:13 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:7 /1Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$47.00 | N/A | Q:9 /1Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
3 |
Preferred Brand |
$47.00 | N/A | Q:7 /1Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$47.00 | N/A | Q:4 /1Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:27 /1Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$47.00 | N/A | Q:27 /1Days |
OXYCODONE-ACETAMINOPHEN 10-325 |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYCODONE-ACETAMINOPHEN 5-325 |
2 |
Generic |
$12.00 | N/A | None |
OXYCODONE-ASPIRIN 4.8355-325 |
3 |
Preferred Brand |
$47.00 | N/A | None |
OXYMORPHONE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:7 /1Days |
OXYMORPHONE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:13 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYMORPHONE HCL ER 15 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:4 /1Days |
OXYMORPHONE HCL ER 7.5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:9 /1Days |