2018 Medicare Part D Plan Formulary Information |
Medicare Plus Blue PPO Vitality (PPO) (H9572-002-1)
Benefit Details
|
The Medicare Plus Blue PPO Vitality (PPO) (H9572-002-1) Formulary Drugs Starting with the Letter O in Barry County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $44.00 Deductible: $405 |
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 |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
25% | N/A | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
25% | N/A | P |
OCTREOTIDE 1,000 MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
OCTREOTIDE ACET 0.05 MG/ML VL |
4 |
Non-Preferred Drug |
50% | 50% | None |
OCTREOTIDE ACET 100 MCG/ML VL |
4 |
Non-Preferred Drug |
50% | 50% | None |
OCTREOTIDE ACET 200 MCG/ML VL |
4 |
Non-Preferred Drug |
50% | 50% | None |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Specialty Tier |
25% | N/A | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2 |
Generic |
$11.00 | $33.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
25% | 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 |
25% | N/A | P |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
OFLOXACIN 0.3 % DRP |
2 |
Generic |
$11.00 | $33.00 | None |
OFLOXACIN 0.3% EAR DROPS |
2 |
Generic |
$11.00 | $33.00 | None |
OFLOXACIN 300 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OFLOXACIN 400 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE 10 MG VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$11.00 | $33.00 | None |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:90 /90Days |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:90 /90Days |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:90 /90Days |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:90 /90Days |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLOPATADINE 665 MCG NASAL SPRY |
2 |
Generic |
$11.00 | $33.00 | None |
OLOPATADINE HCL 0.1% EYE DROPS |
2 |
Generic |
$11.00 | $33.00 | None |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
2 |
Generic |
$11.00 | $33.00 | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
2 |
Generic |
$11.00 | $33.00 | None |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
2 |
Generic |
$11.00 | $33.00 | None |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
2 |
Generic |
$11.00 | $33.00 | None |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OMEPRAZOLE-BICARB 20-1,680 PKT PACKET [Zegerid] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OMEPRAZOLE-BICARB 40-1,680 PACKET [Zegerid] |
4 |
Non-Preferred Drug |
50% | 50% | None |
OMNARIS 50MCG SPRAY NON-AEROSOL |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Specialty Tier |
25% | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
4 |
Non-Preferred Drug |
50% | 50% | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
4 |
Non-Preferred Drug |
50% | 50% | P |
ONDANSETRON 4 MG/2 ML ISECURE |
4 |
Non-Preferred Drug |
50% | 50% | None |
ONDANSETRON 4 MG/5 ML SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
ONDANSETRON HCL 4 MG/2 ML VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
ONDANSETRON ODT 8 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 10 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Drug |
50% | 50% | Q:1440 /90Days |
ONFI 20 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days |
OPDIVO 100 MG/10 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
25% | N/A | P |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
25% | N/A | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | P |
ORENITRAM ER 0.25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | N/A | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
25% | 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 |
25% | N/A | P |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
2 |
Generic |
$11.00 | $33.00 | Q:360 /180Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2 |
Generic |
$11.00 | $33.00 | Q:56 /180Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2 |
Generic |
$11.00 | $33.00 | Q:28 /180Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2 |
Generic |
$11.00 | $33.00 | Q:28 /180Days |
OSMOPREP TABLET 1.5GM |
4 |
Non-Preferred Drug |
50% | 50% | None |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
25% | N/A | P |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OTREXUP 12.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OXACILLIN 1 GM VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
Oxacillin 100 MG/ML Injectable Solution |
4 |
Non-Preferred Drug |
50% | 50% | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
Oxacillin 2000 MG Injection |
4 |
Non-Preferred Drug |
50% | 50% | None |
OXACILLIN 2GM/50ML INJ |
4 |
Non-Preferred Drug |
50% | 50% | None |
OXALIPLATIN 100 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXALIPLATIN 100 MG/20 ML VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
OXANDROLONE 10 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
OXANDROLONE 2.5 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | P |
OXAPROZIN 600 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OXCARBAZEPINE 150 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OXCARBAZEPINE 300 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2 |
Generic |
$11.00 | $33.00 | None |
OXCARBAZEPINE 600 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat] |
2 |
Generic |
$11.00 | $33.00 | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
OXTELLAR XR 600 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2 |
Generic |
$11.00 | $33.00 | None |
OXYBUTYNIN 5MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
OXYBUTYNIN CL ER 10 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | Q:180 /90Days |
OXYBUTYNIN CL ER 15 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | Q:180 /90Days |
OXYBUTYNIN CL ER 5 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | Q:180 /90Days |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2 |
Generic |
$11.00 | $33.00 | Q:540 /90Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
4 |
Non-Preferred Drug |
50% | 50% | Q:540 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2 |
Generic |
$11.00 | $33.00 | Q:540 /90Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2 |
Generic |
$11.00 | $33.00 | Q:540 /90Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2 |
Generic |
$11.00 | $33.00 | Q:540 /90Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
4 |
Non-Preferred Drug |
50% | 50% | Q:3600 /90Days |
OXYCODONE-ACETAMINOPHEN 10-325 |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODONE-ASPIRIN 4.8355-325 |
2 |
Generic |
$11.00 | $33.00 | Q:1080 /90Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
2 |
Generic |
$11.00 | $33.00 | Q:360 /90Days |
OXYMORPHONE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:540 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYMORPHONE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:540 /90Days |
oxymorphone hcl er 10 mg tab |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
OXYMORPHONE HCL ER 15 MG TAB |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
oxymorphone hcl er 20 mg tab |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
oxymorphone hcl er 30 mg tab |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
oxymorphone hcl er 40 mg tab |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
oxymorphone hcl er 5 mg tablet |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |
OXYMORPHONE HCL ER 7.5 MG TAB |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /90Days |