2018 Medicare Part D Plan Formulary Information |
AARP MedicareRx Preferred (PDP) (S5820-020-0)
Benefit Details
 |
The AARP MedicareRx Preferred (PDP) (S5820-020-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $90.00 Deductible: $0 Qualifies for LIS: No |
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 |
OCELLA 3MG/0.03MG TABLET  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OCTAGAM 10% VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCTAGAM 5% VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCTREOTIDE 1,000 MCG/ML VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCTREOTIDE ACET 0.05 MG/ML VL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCTREOTIDE ACET 100 MCG/ML VL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCTREOTIDE ACET 200 MCG/ML VL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCTREOTIDE ACET 500 MCG/ML VL  |
4 |
Non-Preferred Drug |
40% | 40% | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
ODEFSEY TABLET  |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODOMZO 200 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
OFEV 100 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
OFEV 150 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP  |
2 |
Generic |
$8.00 | $0.00 | None |
OFLOXACIN 0.3% EAR DROPS  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OFLOXACIN 300 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OFLOXACIN 400 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OGESTREL TABLET 0.05MG/0.5MG  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OLANZAPINE 10 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE 10 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OLANZAPINE 15 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE 15 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 2.5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE 2.5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE 20 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE 5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE 7.5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] ![Compare how all Medicare Part D PDP plans in LA cover OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] ![Compare how all Medicare Part D PDP plans in LA cover OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] ![Compare how all Medicare Part D PDP plans in LA cover OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN-HCTZ 20-12.5 MG TAB  |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TAB  |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB  |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] ![Compare how all Medicare Part D PDP plans in LA cover olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] ![Compare how all Medicare Part D PDP plans in LA cover olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] ![Compare how all Medicare Part D PDP plans in LA cover olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] ![Compare how all Medicare Part D PDP plans in LA cover olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] ![Compare how all Medicare Part D PDP plans in LA cover olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days |
Olopatadine 2 MG/ML Ophthalmic Solution  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OLOPATADINE HCL 0.1% EYE DROPS  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] ![Compare how all Medicare Part D PDP plans in LA cover OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] ![Compare how all Medicare Part D PDP plans in LA cover OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:90 /30Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] ![Compare how all Medicare Part D PDP plans in LA cover OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | None |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] ![Compare how all Medicare Part D PDP plans in LA cover OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$8.00 | $0.00 | Q:60 /30Days |
ONDANSETRON 4 MG/2 ML ISECURE  |
4 |
Non-Preferred Drug |
40% | 40% | None |
ONDANSETRON 4 MG/5 ML SOLUTION  |
4 |
Non-Preferred Drug |
40% | 40% | P |
ONDANSETRON HCL 24 MG TABLET  |
2 |
Generic |
$8.00 | $0.00 | P |
ONDANSETRON HCL 4 MG TABLET  |
2 |
Generic |
$8.00 | $0.00 | P |
ONDANSETRON HCL 4 MG/2 ML VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | None |
ONDANSETRON HCL 8 MG TABLET  |
2 |
Generic |
$8.00 | $0.00 | P |
ONDANSETRON ODT 4 MG TABLET  |
2 |
Generic |
$8.00 | $0.00 | P |
ONDANSETRON ODT 8 MG TABLET  |
2 |
Generic |
$8.00 | $0.00 | 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 |
40% | 40% | Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION  |
4 |
Non-Preferred Drug |
40% | 40% | None |
ONFI 20 MG TABLET  |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
ONGLYZA 2.5 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
ONGLYZA 5 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
OPDIVO 100 MG/10 ML VIAL  |
5 |
Specialty Tier |
33% | 33% | P |
OPDIVO 40 MG/4 ML VIAL  |
5 |
Specialty Tier |
33% | 33% | P |
OPSUMIT 10 MG TABLET  |
5 |
Specialty Tier |
33% | 33% | P |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE  |
5 |
Specialty Tier |
33% | 33% | P |
ORENITRAM ER 0.125 MG TABLET  |
4 |
Non-Preferred Drug |
40% | 40% | P |
ORENITRAM ER 0.25 MG TABLET  |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENITRAM ER 1 MG TABLET  |
5 |
Specialty Tier |
33% | 33% | P |
ORENITRAM ER 2.5 MG TABLET  |
5 |
Specialty Tier |
33% | 33% | P |
ORFADIN 10 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 2 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 20 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 4 MG/ML SUSPENSION  |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 5 MG CAPSULE  |
5 |
Specialty Tier |
33% | 33% | None |
ORKAMBI 100 MG-125 MG TABLET  |
5 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
ORKAMBI 200 MG-125 MG TABLET  |
5 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
ORPHENADRINE 30 MG/ML VIAL [Norflex] ![Compare how all Medicare Part D PDP plans in LA cover ORPHENADRINE 30 MG/ML VIAL [Norflex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | None |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] ![Compare how all Medicare Part D PDP plans in LA cover OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | Q:780 /30Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] ![Compare how all Medicare Part D PDP plans in LA cover OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] ![Compare how all Medicare Part D PDP plans in LA cover OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] ![Compare how all Medicare Part D PDP plans in LA cover OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
OXACILLIN 1 GM VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | None |
Oxacillin 100 MG/ML Injectable Solution  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXACILLIN 1GM/50ML INJ  |
4 |
Non-Preferred Drug |
40% | 40% | None |
Oxacillin 2000 MG Injection  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXACILLIN 2GM/50ML INJ  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXALIPLATIN 100 MG VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXALIPLATIN 100 MG/20 ML VIAL  |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 10 MG TABLET  |
4 |
Non-Preferred Drug |
40% | 40% | P Q:60 /30Days |
OXANDROLONE 2.5 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | P Q:120 /30Days |
OXCARBAZEPINE 150 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OXCARBAZEPINE 300 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXCARBAZEPINE 600 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | None |
OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat] ![Compare how all Medicare Part D PDP plans in LA cover OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXISTAT 1% LOTION  |
4 |
Non-Preferred Drug |
40% | 40% | None |
OXSORALEN-ULTRA 10MG CAP  |
5 |
Specialty Tier |
33% | 33% | None |
OXYBUTYNIN 5 MG/5 ML SYRUP  |
2 |
Generic |
$8.00 | $0.00 | None |
OXYBUTYNIN 5MG TABLET  |
2 |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CL ER 10 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:60 /30Days |
OXYBUTYNIN CL ER 15 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:60 /30Days |
OXYBUTYNIN CL ER 5 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:30 /30Days |
OXYCODON-ACETAMINOPHEN 2.5-325  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 10 MG TABLET [Dazidox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
40% | 40% | Q:360 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 15 MG TABLET [Roxybond].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:480 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 20 MG TABLET [Roxicodone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 30 MG TABLET [Roxybond].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:240 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 5 MG TABLET [Roxybond].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:7200 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODONE-ASPIRIN 4.8355-325  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:360 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:120 /30Days |
OxyContin 10mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |
OxyContin 15mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |
OxyContin 20mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |
OxyContin 30mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |
OxyContin 40mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |
OxyContin 60mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 80mg/1  |
3 |
Preferred Brand |
$37.00 | $96.00 | Q:90 /30Days |