2019 Medicare Part D Plan Formulary Information |
HumanaChoice H5216-006 (PPO) (H5216-006-0)
Benefit Details
|
The HumanaChoice H5216-006 (PPO) (H5216-006-0) Formulary Drugs Starting with the Letter O in Iowa County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $45.00 Deductible: $250 |
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 |
$100.00 | $290.00 | None |
OCTREOTIDE 1,000 MCG/ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
OCTREOTIDE ACET 0.05 MG/ML VL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
OCTREOTIDE ACET 100 MCG/ML VL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
OCTREOTIDE ACET 200 MCG/ML VL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
OCTREOTIDE ACET 500 MCG/ML VL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
28% | N/A | Q:30 /30Days |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P Q:30 /30Days |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
2* |
Generic |
$15.00 | $0.00 | None |
OFLOXACIN 0.3% EAR DROPS |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OFLOXACIN 300 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OFLOXACIN 400 MG TABLET [Floxin] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
OLANZAPINE 10 MG VIAL |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 5 MG TABLET [Zyprexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TAB |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Olopatadine 2 MG/ML Ophthalmic Solution |
2* |
Generic |
$15.00 | $0.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
3* |
Preferred Brand |
$47.00 | $131.00 | S |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days |
OMEPRAZOLE-BICARB 20-1,680 PKT PACKET [Zegerid] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days |
OMEPRAZOLE-BICARB 40-1,680 PACKET [Zegerid] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days |
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 |
28% | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
28% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
5 |
Specialty Tier |
28% | N/A | P |
ONDANSETRON 4 MG/5 ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:450 /30Days |
ONDANSETRON HCL 24 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | P Q:30 /30Days |
ONDANSETRON HCL 4 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | P Q:90 /30Days |
ONDANSETRON HCL 8 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | P Q:90 /30Days |
ONDANSETRON ODT 4 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | P Q:90 /30Days |
ONDANSETRON ODT 8 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | P Q:90 /30Days |
ONFI 10 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
5 |
Specialty Tier |
28% | N/A | P Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 20 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
ONGLYZA 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
ONGLYZA 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:30 /30Days |
ORACEA CAPSULES 40MG 30 BOT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
28% | N/A | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | None |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:112 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORKAMBI 100-125 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
28% | N/A | P Q:56 /28Days |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
28% | N/A | P Q:56 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:112 /28Days |
ORSYTHIA-28 TABLET [Vienva] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ORTHO-NOVUM 7-7-7-28 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1440 /365Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:224 /365Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:112 /365Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:112 /365Days |
OSENI 12.5-15 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OSENI 12.5-30 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSENI 12.5-45 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OSENI 25-15 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OSENI 25-30 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OSENI 25-45 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days |
OXACILLIN 1 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Oxacillin 100 MG/ML Injectable Solution |
5 |
Specialty Tier |
28% | N/A | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Oxacillin 2000 MG Injection |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OXACILLIN 2GM/50ML INJ |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OXANDROLONE 10 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
OXANDROLONE 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days |
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 |
$100.00 | $290.00 | None |
OXAZEPAM 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OXAZEPAM 15 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OXAZEPAM 30 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OXCARBAZEPINE 150 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
OXCARBAZEPINE 300 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
OXCARBAZEPINE 600 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2* |
Generic |
$15.00 | $0.00 | None |
OXYBUTYNIN 5MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
OXYBUTYNIN CL ER 10 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | 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 |
$47.00 | $131.00 | Q:60 /30Days |
OXYBUTYNIN CL ER 5 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
OXYCODON-ACETAMINOPHEN 2.5-325 |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325 |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:270 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
3* |
Preferred Brand |
$47.00 | $131.00 | 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] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:5400 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:360 /30Days |
OXYMORPHONE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:360 /30Days |
OXYMORPHONE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:360 /30Days |
OZEMPIC 0.25-0.5 MG DOSE PEN |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days |
OZEMPIC 1 MG DOSE PEN |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days |