2018 Medicare Part D Plan Formulary Information |
Express Scripts Medicare - Choice (PDP) (S5660-192-0)
Benefit Details
|
The Express Scripts Medicare - Choice (PDP) (S5660-192-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 22 which includes: TX Plan Monthly Premium: $105.70 Deductible: $350 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 |
OCALIVA 10 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:31 /31Days |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:31 /31Days |
OCELLA 3MG/0.03MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OCTREOTIDE 1,000 MCG/ML VIAL |
5 |
Specialty Tier |
26% | N/A | None |
OCTREOTIDE ACET 0.05 MG/ML VL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OCTREOTIDE ACET 100 MCG/ML VL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OCTREOTIDE ACET 200 MCG/ML VL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Specialty Tier |
26% | N/A | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2* |
Generic |
$7.00 | $4.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
26% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
26% | N/A | P Q:31 /31Days |
OFEV 100 MG CAPSULE |
4 |
Non-Preferred Drug |
48% | N/A | P Q:62 /31Days |
OFEV 150 MG CAPSULE |
4 |
Non-Preferred Drug |
48% | N/A | P Q:62 /31Days |
OFLOXACIN 0.3 % DRP |
2* |
Generic |
$7.00 | $4.00 | None |
OFLOXACIN 0.3% EAR DROPS |
2* |
Generic |
$7.00 | $4.00 | None |
OFLOXACIN 300 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OFLOXACIN 400 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2* |
Generic |
$7.00 | $4.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2* |
Generic |
$7.00 | $4.00 | P Q:62 /31Days |
OLANZAPINE 10 MG VIAL |
2* |
Generic |
$7.00 | $4.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2* |
Generic |
$7.00 | $4.00 | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2* |
Generic |
$7.00 | $4.00 | P Q:248 /31Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2* |
Generic |
$7.00 | $4.00 | P Q:31 /31Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2* |
Generic |
$7.00 | $4.00 | P Q:124 /31Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2* |
Generic |
$7.00 | $4.00 | P Q:83 /31Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$7.00 | $4.00 | P Q:62 /31Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$7.00 | $4.00 | P Q:31 /31Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$7.00 | $4.00 | P Q:31 /31Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$7.00 | $4.00 | P Q:124 /31Days |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
48% | N/A | None |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
48% | N/A | None |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
48% | N/A | None |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
48% | N/A | None |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
2* |
Generic |
$7.00 | $4.00 | None |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
2* |
Generic |
$7.00 | $4.00 | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
2* |
Generic |
$7.00 | $4.00 | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
2* |
Generic |
$7.00 | $4.00 | None |
OLMESARTAN-HCTZ 40-12.5 MG TAB |
2* |
Generic |
$7.00 | $4.00 | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
2* |
Generic |
$7.00 | $4.00 | None |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
4 |
Non-Preferred Drug |
48% | N/A | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:31 /31Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:31 /31Days |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
48% | N/A | Q:31 /31Days |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
48% | N/A | None |
ONDANSETRON 4 MG/5 ML SOLUTION |
2* |
Generic |
$7.00 | $4.00 | P |
ONDANSETRON HCL 24 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 4 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | P |
ONDANSETRON HCL 4 MG/2 ML VIAL |
2* |
Generic |
$7.00 | $4.00 | None |
ONDANSETRON HCL 8 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | P |
ONDANSETRON ODT 4 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | P |
ONDANSETRON ODT 8 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | P |
ONFI 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
ONFI 2.5 MG/ML SUSPENSION |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
ONFI 20 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P |
ONGLYZA 2.5 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | Q:31 /31Days |
ONGLYZA 5 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | Q:31 /31Days |
OPDIVO 100 MG/10 ML VIAL |
5 |
Specialty Tier |
26% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPDIVO 40 MG/4 ML VIAL |
5 |
Specialty Tier |
26% | N/A | P |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
26% | N/A | P |
ORENCIA 250MG VIAL |
5 |
Specialty Tier |
26% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
26% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
26% | N/A | P |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
26% | N/A | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
26% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
26% | N/A | None |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
26% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
26% | N/A | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
26% | 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 |
26% | N/A | P Q:112 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:112 /28Days |
Orsythia 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$7.00 | $4.00 | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
OXALIPLATIN 100 MG VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
OXALIPLATIN 100 MG/20 ML VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
OXANDROLONE 10 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P |
OXANDROLONE 2.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXAPROZIN 600 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
OXCARBAZEPINE 150 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXCARBAZEPINE 300 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2* |
Generic |
$7.00 | $4.00 | None |
OXCARBAZEPINE 600 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2* |
Generic |
$7.00 | $4.00 | None |
OXYBUTYNIN 5MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXYBUTYNIN CL ER 10 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXYBUTYNIN CL ER 15 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXYBUTYNIN CL ER 5 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2* |
Generic |
$7.00 | $4.00 | Q:186 /31Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
2* |
Generic |
$7.00 | $4.00 | Q:186 /31Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2* |
Generic |
$7.00 | $4.00 | Q:186 /31Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2* |
Generic |
$7.00 | $4.00 | Q:186 /31Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2* |
Generic |
$7.00 | $4.00 | Q:186 /31Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
4 |
Non-Preferred Drug |
48% | N/A | Q:1240 /31Days |
OXYCODONE-ACETAMINOPHEN 10-325 |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-ASPIRIN 4.8355-325 |
2* |
Generic |
$7.00 | $4.00 | Q:372 /31Days |
oxymorphone hcl er 10 mg tab |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |
OXYMORPHONE HCL ER 15 MG TAB |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |
oxymorphone hcl er 20 mg tab |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |
oxymorphone hcl er 30 mg tab |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |
oxymorphone hcl er 40 mg tab |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |
oxymorphone hcl er 5 mg tablet |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |
OXYMORPHONE HCL ER 7.5 MG TAB |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:93 /31Days |