2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 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  |
3 |
Preferred Brand |
$46.00 | N/A | None |
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  |
4 |
Non-Preferred Drug |
37% | N/A | P |
OCTREOTIDE ACET 0.05 MG/ML VL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
OCTREOTIDE ACET 100 MCG/ML VL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
OCTREOTIDE ACET 200 MCG/ML VL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
OCTREOTIDE ACET 500 MCG/ML VL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
OCUFLOX 0.3% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODEFSEY TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
ODOMZO 200 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
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  |
3 |
Preferred Brand |
$46.00 | N/A | None |
OFLOXACIN 0.3% EAR DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OFLOXACIN 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OFLOXACIN 400 MG TABLET  |
2* |
Generic |
$3.00 | N/A | 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) |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
OLANZAPINE 10 MG VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
3 |
Preferred Brand |
$46.00 | N/A | 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) |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /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) |
3 |
Preferred Brand |
$46.00 | N/A | 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) |
3 |
Preferred Brand |
$46.00 | N/A | 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) |
3 |
Preferred Brand |
$46.00 | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] ![Compare how all Medicare Part D PDP plans in LA cover OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | 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) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
Olopatadine 2 MG/ML Ophthalmic Solution  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OLOPATADINE 665 MCG NASAL SPRY  |
4 |
Non-Preferred Drug |
37% | N/A | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLUX 0.05% FOAM  |
4 |
Non-Preferred Drug |
37% | N/A | 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 |
37% | N/A | Q:120 /30Days |
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 |
$3.00 | N/A | Q:30 /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 |
$3.00 | N/A | Q:30 /30Days |
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 |
$3.00 | N/A | Q:60 /30Days |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] ![Compare how all Medicare Part D PDP plans in LA cover OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] ![Compare how all Medicare Part D PDP plans in LA cover OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
OMNARIS 50MCG SPRAY NON-AEROSOL  |
4 |
Non-Preferred Drug |
37% | N/A | Q:13 /30Days |
OMNIPRED OPHTHALMIC SUSPENSION 1% 10 ML BOTPL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ONDANSETRON 4 MG/2 ML ISECURE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ONDANSETRON 4 MG/5 ML SOLUTION  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:900 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 24 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
ONDANSETRON HCL 4 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
ONDANSETRON HCL 4 MG/2 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ONDANSETRON HCL 8 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
ONDANSETRON ODT 4 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
ONDANSETRON ODT 8 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
ONFI 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
ONFI 2.5 MG/ML SUSPENSION  |
5 |
Specialty Tier |
25% | N/A | P |
ONFI 20 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
ONZETRA XSAIL 11 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:16 /30Days |
OPANA 10MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA 5MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
OPDIVO 100 MG/10 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
OPDIVO 40 MG/4 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
OPSUMIT 10 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
ORACEA CAPSULES 40MG 30 BOT  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
ORAPRED ODT 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ORAPRED ODT 15 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ORAPRED ODT 30 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ORAVIG 50 MG BUCCAL TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
ORFADIN 10 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
ORFADIN 2 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 |
ORFADIN 20 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
ORFADIN 4 MG/ML SUSPENSION  |
5 |
Specialty Tier |
25% | N/A | P |
ORFADIN 5 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
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 |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ORTHO TRI-CYCLEN LO TABLET [Trinessa Lo] ![Compare how all Medicare Part D PDP plans in LA cover ORTHO TRI-CYCLEN LO TABLET [Trinessa Lo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
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 |
37% | N/A | None |
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 |
37% | N/A | None |
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 |
37% | N/A | None |
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 |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSMOPREP TABLET 1.5GM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 10 MG/0.4 ML AUTO-INJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 12.5 MG/0.4 ML AUTOINJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 15 MG/0.4 ML AUTO-INJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 17.5 MG/0.4 ML AUTOINJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 20 MG/0.4 ML AUTO-INJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 22.5 MG/0.4 ML AUTOINJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OTREXUP 25 MG/0.4 ML AUTO-INJ  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OVIDE 0.5% LOTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXACILLIN 1 GM VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Oxacillin 100 MG/ML Injectable Solution  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Oxacillin 2000 MG Injection  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXALIPLATIN 100 MG VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXALIPLATIN 100 MG/20 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXANDROLONE 10 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
OXANDROLONE 2.5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
OXAPROZIN 600 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXAZEPAM 10 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
OXAZEPAM 15 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
OXAZEPAM 30 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
OXCARBAZEPINE 150 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
OXCARBAZEPINE 300 MG TABLET  |
3 |
Preferred Brand |
$46.00 | 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  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXCARBAZEPINE 600 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | 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 |
37% | N/A | None |
OXISTAT 1% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXISTAT 1% LOTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
OXTELLAR XR 150 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
OXTELLAR XR 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
OXTELLAR XR 600 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
OXYBUTYNIN 5 MG/5 ML SYRUP  |
2* |
Generic |
$3.00 | N/A | Q:600 /30Days |
OXYBUTYNIN 5MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:120 /30Days |
OXYBUTYNIN CL ER 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CL ER 15 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
OXYBUTYNIN CL ER 5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
OXYCODON-ACETAMINOPHEN 2.5-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /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 |
$46.00 | N/A | Q:180 /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 |
37% | N/A | Q:180 /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 |
$46.00 | N/A | Q:180 /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 |
$46.00 | N/A | Q:180 /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 |
$46.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL 5 MG CAPSULE [OxyIR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /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 |
$46.00 | N/A | Q:180 /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 |
$46.00 | N/A | Q:5400 /30Days |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:60 /30Days |
OXYCODONE HCL ER 80 MG TABLET 12H [OxyContin] ![Compare how all Medicare Part D PDP plans in LA cover OXYCODONE HCL ER 80 MG TABLET 12H [OxyContin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:120 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
OXYCODONE-ASPIRIN 4.8355-325  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-IBUPROFEN 5-400 TAB  |
3 |
Preferred Brand |
$46.00 | N/A | Q:120 /30Days |
OXYMORPHONE HCL 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
OXYMORPHONE HCL 5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
oxymorphone hcl er 10 mg tab  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
OXYMORPHONE HCL ER 15 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
oxymorphone hcl er 20 mg tab  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
oxymorphone hcl er 30 mg tab  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
oxymorphone hcl er 40 mg tab  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
oxymorphone hcl er 5 mg tablet  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
OXYMORPHONE HCL ER 7.5 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
OXYTROL 3.9mg/d 8 POUCH in 1 BOX / 1 PATCH in 1 POUCH / 4 d in 1 PATCH  |
4 |
Non-Preferred Drug |
37% | N/A | Q:8 /28Days |