2019 Medicare Part D Plan Formulary Information |
CareAdvantage Premier (HMO) (H5273-003-0)
Benefit Details
|
The CareAdvantage Premier (HMO) (H5273-003-0) Formulary Drugs Starting with the Letter O in Litchfield County, CT: CMS MA Region 2 which includes: CT Plan Monthly Premium: $89.00 Deductible: $0 |
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 |
33% | N/A | P Q:30 /30Days |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OCTAGAM 10% VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
OCTAGAM 5% VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
OCTREOTIDE 1,000 MCG/ML VIAL |
2 |
Generic |
$12.00 | $24.00 | None |
OCTREOTIDE ACET 0.05 MG/ML VL |
2 |
Generic |
$12.00 | $24.00 | None |
OCTREOTIDE ACET 100 MCG/ML VL |
2 |
Generic |
$12.00 | $24.00 | None |
OCTREOTIDE ACET 200 MCG/ML VL |
2 |
Generic |
$12.00 | $24.00 | None |
OCTREOTIDE ACET 500 MCG/ML VL |
2 |
Generic |
$12.00 | $24.00 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2 |
Generic |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODEFSEY TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OFLOXACIN 0.3 % DRP |
2 |
Generic |
$12.00 | $24.00 | None |
OFLOXACIN 0.3% EAR DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OFLOXACIN 400 MG TABLET [Floxin] |
2 |
Generic |
$12.00 | $24.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE 10 MG VIAL |
2 |
Generic |
$12.00 | $24.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | $24.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
2 |
Generic |
$12.00 | $24.00 | S |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
2 |
Generic |
$12.00 | $24.00 | S |
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 |
$12.00 | $24.00 | S |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
3 |
Preferred Brand |
$45.00 | $90.00 | 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] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Olopatadine 2 MG/ML Ophthalmic Solution |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
2 |
Generic |
$12.00 | $24.00 | Q:92 /90Days |
OLOPATADINE HCL 0.1% EYE DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OMEPRAZOLE-BICARB 20-1,100 CAP [Zegerid] |
5 |
Specialty Tier |
33% | N/A | None |
OMEPRAZOLE-BICARB 20-1,680 PKT PACKET [Zegerid] |
5 |
Specialty Tier |
33% | N/A | None |
OMEPRAZOLE-BICARB 40-1,100 CAP [Zegerid] |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE-BICARB 40-1,680 PACKET [Zegerid] |
5 |
Specialty Tier |
33% | N/A | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Specialty Tier |
33% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
ONDANSETRON 4 MG/5 ML SOLUTION |
2 |
Generic |
$12.00 | $24.00 | P |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | P |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | P |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | P |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | P |
ONDANSETRON ODT 8 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | P |
ONFI 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 2.5 MG/ML SUSPENSION |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
ONFI 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ORALAIR 300 IR SUBLINGUAL TAB |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
ORAPRED ODT 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
ORAPRED ODT 15 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
ORAPRED ODT 30 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
ORENITRAM ER 0.25 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
ORENITRAM ER 1 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENITRAM ER 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | N/A | P |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ORILISSA 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ORILISSA 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
ORKAMBI 100-125 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
33% | N/A | P Q:56 /28Days |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
33% | N/A | P Q:56 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
ORSYTHIA-28 TABLET [Vienva] |
2 |
Generic |
$12.00 | $24.00 | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OSMOPREP TABLET 1.5GM |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
OSPHENA 60 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
OXACILLIN 1 GM VIAL |
2 |
Generic |
$12.00 | $24.00 | None |
Oxacillin 100 MG/ML Injectable Solution |
2 |
Generic |
$12.00 | $24.00 | None |
OXACILLIN 1GM/50ML INJ |
2 |
Generic |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Oxacillin 2000 MG Injection |
2 |
Generic |
$12.00 | $24.00 | None |
OXACILLIN 2GM/50ML INJ |
2 |
Generic |
$12.00 | $24.00 | None |
OXANDROLONE 10 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXANDROLONE 2.5 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXAPROZIN 600 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXAZEPAM 10 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OXAZEPAM 15 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OXAZEPAM 30 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OXCARBAZEPINE 150 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXCARBAZEPINE 300 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2 |
Generic |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXCARBAZEPINE 600 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXERVATE 0.002% EYE DROPS |
5 |
Specialty Tier |
33% | N/A | P |
OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OXISTAT 1% LOTION |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
OXTELLAR XR 600 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OXYBUTYNIN 5MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
OXYBUTYNIN CL ER 10 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXYBUTYNIN CL ER 15 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CL ER 5 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2 |
Generic |
$12.00 | $24.00 | Q:180 /30Days |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
2 |
Generic |
$12.00 | $24.00 | Q:120 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2 |
Generic |
$12.00 | $24.00 | Q:180 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2 |
Generic |
$12.00 | $24.00 | Q:120 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2 |
Generic |
$12.00 | $24.00 | Q:120 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
2 |
Generic |
$12.00 | $24.00 | Q:2400 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE HCL ER 80 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODONE-ASPIRIN 4.8355-325 |
2 |
Generic |
$12.00 | $24.00 | Q:240 /30Days |
OXYCODONE-IBUPROFEN 5-400 TAB |
2 |
Generic |
$12.00 | $24.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 10mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OxyContin 15mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OxyContin 20mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OxyContin 30mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OxyContin 40mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OxyContin 60mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OxyContin 80mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
OXYMORPHONE HCL 10 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | Q:180 /30Days |
OXYMORPHONE HCL 5 MG TABLET |
2 |
Generic |
$12.00 | $24.00 | Q:180 /30Days |
oxymorphone hcl er 10 mg tab |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
OXYMORPHONE HCL ER 15 MG TAB |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxymorphone hcl er 20 mg tab |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
oxymorphone hcl er 30 mg tab |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
oxymorphone hcl er 40 mg tab |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
oxymorphone hcl er 5 mg tablet |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
OXYMORPHONE HCL ER 7.5 MG TAB |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days |
OZEMPIC 0.25-0.5 MG DOSE PEN |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
OZEMPIC 1 MG DOSE PEN |
3 |
Preferred Brand |
$45.00 | $90.00 | None |