2019 Medicare Part D Plan Formulary Information |
MedMutual Advantage Preferred (PPO) (H4497-002-1)
Benefit Details
|
The MedMutual Advantage Preferred (PPO) (H4497-002-1) Formulary Drugs Starting with the Letter O in Holmes County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $74.00 Deductible: $55 |
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 |
32% | N/A | P Q:30 /30Days |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P Q:30 /30Days |
OCTREOTIDE 1,000 MCG/ML VIAL |
5 |
Specialty Tier |
32% | N/A | None |
OCTREOTIDE ACET 0.05 MG/ML VL |
2* |
Generic |
$10.00 | $22.00 | None |
OCTREOTIDE ACET 100 MCG/ML VL |
2* |
Generic |
$10.00 | $22.00 | None |
OCTREOTIDE ACET 200 MCG/ML VL |
2* |
Generic |
$10.00 | $22.00 | None |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Specialty Tier |
32% | N/A | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2* |
Generic |
$10.00 | $22.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
32% | N/A | None |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | P Q:60 /30Days |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
2* |
Generic |
$10.00 | $22.00 | None |
OFLOXACIN 0.3% EAR DROPS |
2* |
Generic |
$10.00 | $22.00 | None |
OFLOXACIN 300 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OFLOXACIN 400 MG TABLET [Floxin] |
2* |
Generic |
$10.00 | $22.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2* |
Generic |
$10.00 | $22.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL |
2* |
Generic |
$10.00 | $22.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2* |
Generic |
$10.00 | $22.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
2* |
Generic |
$10.00 | $22.00 | None |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
2* |
Generic |
$10.00 | $22.00 | None |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
2* |
Generic |
$10.00 | $22.00 | None |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
2* |
Generic |
$10.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
2* |
Generic |
$10.00 | $22.00 | None |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
2* |
Generic |
$10.00 | $22.00 | None |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
2* |
Generic |
$10.00 | $22.00 | None |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
2* |
Generic |
$10.00 | $22.00 | None |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
2* |
Generic |
$10.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
2* |
Generic |
$10.00 | $22.00 | None |
Olopatadine 2 MG/ML Ophthalmic Solution |
2* |
Generic |
$10.00 | $22.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
2* |
Generic |
$10.00 | $22.00 | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2* |
Generic |
$10.00 | $22.00 | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Specialty Tier |
32% | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
32% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5 |
Specialty Tier |
32% | N/A | P |
ONDANSETRON 4 MG/5 ML SOLUTION |
2* |
Generic |
$10.00 | $22.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 24 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | P |
ONDANSETRON HCL 4 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | P |
ONDANSETRON HCL 8 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | P |
ONDANSETRON ODT 4 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | P |
ONDANSETRON ODT 8 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | P |
ONFI 10 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
5 |
Specialty Tier |
32% | N/A | P Q:480 /30Days |
ONFI 20 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P Q:60 /30Days |
ONGLYZA 2.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
32% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
32% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
32% | N/A | P |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
32% | N/A | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | None |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
32% | N/A | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
32% | N/A | None |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P Q:112 /28Days |
ORKAMBI 100-125 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
32% | N/A | P Q:56 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
32% | N/A | P Q:56 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P Q:112 /28Days |
ORSYTHIA-28 TABLET [Vienva] |
2* |
Generic |
$10.00 | $22.00 | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
2* |
Generic |
$10.00 | $22.00 | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2* |
Generic |
$10.00 | $22.00 | None |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2* |
Generic |
$10.00 | $22.00 | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2* |
Generic |
$10.00 | $22.00 | None |
OTEZLA 28 DAY STARTER PACK |
5 |
Specialty Tier |
32% | N/A | P |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P |
OTOVEL 0.3%-0.025% EAR DROPS |
3 |
Preferred Brand |
$42.00 | $110.00 | None |
OXACILLIN 1 GM VIAL |
2* |
Generic |
$10.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Oxacillin 100 MG/ML Injectable Solution |
5 |
Specialty Tier |
32% | N/A | None |
OXACILLIN 1GM/50ML INJ |
2* |
Generic |
$10.00 | $22.00 | None |
Oxacillin 2000 MG Injection |
2* |
Generic |
$10.00 | $22.00 | None |
OXACILLIN 2GM/50ML INJ |
2* |
Generic |
$10.00 | $22.00 | None |
OXANDROLONE 10 MG TABLET |
5 |
Specialty Tier |
32% | N/A | P |
OXANDROLONE 2.5 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | P |
OXAPROZIN 600 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXCARBAZEPINE 150 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXCARBAZEPINE 300 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2* |
Generic |
$10.00 | $22.00 | None |
OXCARBAZEPINE 600 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXERVATE 0.002% EYE DROPS |
5 |
Specialty Tier |
32% | N/A | P |
OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat] |
2* |
Generic |
$10.00 | $22.00 | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2* |
Generic |
$10.00 | $22.00 | None |
OXYBUTYNIN 5MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXYBUTYNIN CL ER 10 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXYBUTYNIN CL ER 15 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXYBUTYNIN CL ER 5 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2* |
Generic |
$10.00 | $22.00 | Q:180 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
2* |
Generic |
$10.00 | $22.00 | Q:180 /30Days |
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 |
$10.00 | $22.00 | Q:180 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2* |
Generic |
$10.00 | $22.00 | Q:180 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2* |
Generic |
$10.00 | $22.00 | Q:180 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
2* |
Generic |
$10.00 | $22.00 | Q:1200 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
2* |
Generic |
$10.00 | $22.00 | Q:28 /30Days |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:90 /30Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:90 /30Days |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:90 /30Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:90 /30Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:90 /30Days |
OxyContin 80mg/1 |
5 |
Specialty Tier |
32% | N/A | P Q:60 /30Days |
OXYMORPHONE HCL 10 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | Q:360 /30Days |
OXYMORPHONE HCL 5 MG TABLET |
2* |
Generic |
$10.00 | $22.00 | Q:180 /30Days |
OZEMPIC 0.25-0.5 MG DOSE PEN |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:2 /28Days |
OZEMPIC 1 MG DOSE PEN |
3 |
Preferred Brand |
$42.00 | $110.00 | P Q:3 /28Days |