2018 Medicare Part D Plan Formulary Information |
Network PlatinumChoice (PPO) (H5215-011-0)
Benefit Details
|
The Network PlatinumChoice (PPO) (H5215-011-0) Formulary Drugs Starting with the Letter O in Brown County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $22.00 Deductible: $260 |
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 |
27% | N/A | P |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
OCELLA 3MG/0.03MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
27% | N/A | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
27% | N/A | P |
OCTREOTIDE 1,000 MCG/ML VIAL |
5 |
Specialty Tier |
27% | N/A | None |
OCTREOTIDE ACET 0.05 MG/ML VL |
2* |
Generic |
$8.00 | N/A | None |
OCTREOTIDE ACET 100 MCG/ML VL |
2* |
Generic |
$8.00 | N/A | None |
OCTREOTIDE ACET 200 MCG/ML VL |
2* |
Generic |
$8.00 | N/A | None |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Specialty Tier |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUFLOX 0.3% EYE DROPS |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2* |
Generic |
$8.00 | N/A | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
27% | N/A | None |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | P |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | P |
OFLOXACIN 0.3 % DRP |
2* |
Generic |
$8.00 | N/A | None |
OFLOXACIN 0.3% EAR DROPS |
2* |
Generic |
$8.00 | N/A | None |
OFLOXACIN 300 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OFLOXACIN 400 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OGESTREL TABLET 0.05MG/0.5MG |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE 10 MG VIAL |
2* |
Generic |
$8.00 | N/A | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$8.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
2* |
Generic |
$8.00 | N/A | S |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
2* |
Generic |
$8.00 | N/A | None |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
2* |
Generic |
$8.00 | N/A | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
2* |
Generic |
$8.00 | N/A | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
2* |
Generic |
$8.00 | N/A | None |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
2* |
Generic |
$8.00 | N/A | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
2* |
Generic |
$8.00 | N/A | None |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
2* |
Generic |
$8.00 | N/A | None |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
2* |
Generic |
$8.00 | N/A | None |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
2* |
Generic |
$8.00 | N/A | None |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
2* |
Generic |
$8.00 | N/A | None |
Olopatadine 2 MG/ML Ophthalmic Solution |
2* |
Generic |
$8.00 | N/A | None |
OLOPATADINE 665 MCG NASAL SPRY |
2* |
Generic |
$8.00 | N/A | Q:61 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2* |
Generic |
$8.00 | N/A | None |
OLUMIANT 2 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
OLUX 0.05% FOAM |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OMECLAMOX-PAK COMBO PACK |
4 |
Non-Preferred Brand |
$84.00 | 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 Brand |
$84.00 | N/A | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$2.00 | N/A | Q:30 /30Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$2.00 | N/A | None |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$2.00 | N/A | None |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OMEPRAZOLE-BICARB 20-1,680 PKT PACKET [Zegerid] |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] |
2* |
Generic |
$8.00 | N/A | None |
OMEPRAZOLE-BICARB 40-1,680 PACKET [Zegerid] |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OMNARIS 50MCG SPRAY NON-AEROSOL |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:25 /30Days |
OMNIPRED OPHTHALMIC SUSPENSION 1% 10 ML BOTPL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Specialty Tier |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
27% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5 |
Specialty Tier |
27% | N/A | P |
ONDANSETRON 4 MG/2 ML ISECURE |
2* |
Generic |
$8.00 | N/A | None |
ONDANSETRON 4 MG/5 ML SOLUTION |
2* |
Generic |
$8.00 | N/A | P |
ONDANSETRON HCL 24 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
ONDANSETRON HCL 4 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
ONDANSETRON HCL 4 MG/2 ML VIAL |
2* |
Generic |
$8.00 | N/A | None |
ONDANSETRON HCL 8 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
ONDANSETRON ODT 4 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
ONDANSETRON ODT 8 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
ONEXTON GEL PUMP |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
ONFI 2.5 MG/ML SUSPENSION |
3 |
Preferred Brand |
$42.00 | N/A | P |
ONFI 20 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | Q:30 /30Days |
ONZETRA XSAIL 11 MG |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:32 /28Days |
OPANA 10MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:360 /30Days |
OPANA 5MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:180 /30Days |
OPDIVO 100 MG/10 ML VIAL |
5 |
Specialty Tier |
27% | N/A | P |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
27% | N/A | P |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORACEA CAPSULES 40MG 30 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORALAIR 300 IR SUBLINGUAL TAB |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORAP 1MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORAPRED ODT 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORAPRED ODT 15 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORAPRED ODT 30 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORAVIG 50 MG BUCCAL TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORBACTIV 400 MG VIAL |
5 |
Specialty Tier |
27% | N/A | None |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
27% | N/A | P |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
27% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
27% | N/A | P |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
27% | N/A | P |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
27% | N/A | None |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORENITRAM ER 0.25 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
ORPHENADRINE 30 MG/ML VIAL [Norflex] |
3 |
Preferred Brand |
$42.00 | N/A | None |
ORPHENADRINE ER 100 MG TABLET [Norflex] |
3 |
Preferred Brand |
$42.00 | N/A | P |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$8.00 | N/A | None |
ORTHO MICRONOR 0.35 MG TABLET [Sharobel 28-Day] |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORTHO TRI-CYCLEN 28 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORTHO TRI-CYCLEN LO TABLET [Trinessa Lo] |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORTHO-CYCLEN 28 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
ORTHO-NOVUM 1-35-28 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORTHO-NOVUM 7-7-7-28 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
2* |
Generic |
$8.00 | N/A | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2* |
Generic |
$8.00 | N/A | None |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2* |
Generic |
$8.00 | N/A | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2* |
Generic |
$8.00 | N/A | None |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSMOPREP TABLET 1.5GM |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OSPHENA 60 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
27% | N/A | P |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
OTOVEL 0.3%-0.025% EAR DROPS |
3 |
Preferred Brand |
$42.00 | N/A | None |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OTREXUP 12.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OVIDE 0.5% LOTION |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OXACILLIN 1 GM VIAL |
2* |
Generic |
$8.00 | N/A | None |
Oxacillin 100 MG/ML Injectable Solution |
5 |
Specialty Tier |
27% | N/A | None |
OXACILLIN 1GM/50ML INJ |
2* |
Generic |
$8.00 | N/A | None |
Oxacillin 2000 MG Injection |
2* |
Generic |
$8.00 | N/A | None |
OXACILLIN 2GM/50ML INJ |
5 |
Specialty Tier |
27% | N/A | None |
OXALIPLATIN 100 MG VIAL |
3 |
Preferred Brand |
$42.00 | N/A | P |
OXALIPLATIN 100 MG/20 ML VIAL |
3 |
Preferred Brand |
$42.00 | N/A | P |
OXANDROLONE 10 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
OXANDROLONE 2.5 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXAPROZIN 600 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXAZEPAM 10 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | P |
OXAZEPAM 15 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | P |
OXAZEPAM 30 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | P |
OXCARBAZEPINE 150 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXCARBAZEPINE 300 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2* |
Generic |
$8.00 | N/A | None |
OXCARBAZEPINE 600 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat] |
2* |
Generic |
$8.00 | N/A | None |
OXISTAT 1% CREAM |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXSORALEN-ULTRA 10MG CAP |
5 |
Specialty Tier |
27% | N/A | None |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
OXTELLAR XR 600 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2* |
Generic |
$8.00 | N/A | None |
OXYBUTYNIN 5MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXYBUTYNIN CL ER 10 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXYBUTYNIN CL ER 15 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXYBUTYNIN CL ER 5 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:1200 /30Days |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
OXYCODONE HCL ER 80 MG TABLET 12H [OxyContin] |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:60 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325 |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
2* |
Generic |
$8.00 | N/A | Q:28 /30Days |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:90 /30Days |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:90 /30Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:90 /30Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:90 /30Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:90 /30Days |
OxyContin 80mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | Q:60 /30Days |
OXYMORPHONE HCL 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:360 /30Days |
OXYMORPHONE HCL 5 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
oxymorphone hcl er 10 mg tab |
2* |
Generic |
$8.00 | N/A | Q:90 /30Days |
OXYMORPHONE HCL ER 15 MG TAB |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
oxymorphone hcl er 20 mg tab |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
oxymorphone hcl er 30 mg tab |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:90 /30Days |
oxymorphone hcl er 40 mg tab |
2* |
Generic |
$8.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxymorphone hcl er 5 mg tablet |
2* |
Generic |
$8.00 | N/A | Q:90 /30Days |
OXYMORPHONE HCL ER 7.5 MG TAB |
2* |
Generic |
$8.00 | N/A | Q:90 /30Days |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
OZEMPIC 0.25-0.5 MG DOSE PEN |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:2 /30Days |
OZEMPIC 1 MG DOSE PEN |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:3 /30Days |