2019 Medicare Part D Plan Formulary Information |
Farm Bureau Select Rx (PDP) (S2668-006-0)
Benefit Details
|
The Farm Bureau Select Rx (PDP) (S2668-006-0) Formulary Drugs Starting with the Letter O in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $99.00 Deductible: $0 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 |
33% | 33% | P Q:30 /30Days |
OCALIVA 5 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
OCELLA 3MG/0.03MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
33% | 33% | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
33% | 33% | P |
OCTREOTIDE 1,000 MCG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
OCTREOTIDE ACET 0.05 MG/ML VL |
4 |
Non-Preferred Drug |
45% | 45% | P |
OCTREOTIDE ACET 100 MCG/ML VL |
4 |
Non-Preferred Drug |
45% | 45% | P |
OCTREOTIDE ACET 200 MCG/ML VL |
4 |
Non-Preferred Drug |
45% | 45% | P |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2 |
Generic |
$8.00 | $24.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
ODOMZO 200 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
OFEV 100 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
OFEV 150 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
OFLOXACIN 0.3 % DRP |
2 |
Generic |
$8.00 | $24.00 | None |
OFLOXACIN 0.3% EAR DROPS |
2 |
Generic |
$8.00 | $24.00 | None |
OFLOXACIN 300 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OFLOXACIN 400 MG TABLET [Floxin] |
2 |
Generic |
$8.00 | $24.00 | None |
OGESTREL TABLET 0.05MG/0.5MG |
2 |
Generic |
$8.00 | $24.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 10 MG VIAL |
2 |
Generic |
$8.00 | $24.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
2 |
Generic |
$8.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
2 |
Generic |
$8.00 | $24.00 | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
2 |
Generic |
$8.00 | $24.00 | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
2 |
Generic |
$8.00 | $24.00 | None |
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT] |
2 |
Generic |
$8.00 | $24.00 | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
2 |
Generic |
$8.00 | $24.00 | None |
Olopatadine 2 MG/ML Ophthalmic Solution |
2 |
Generic |
$8.00 | $24.00 | None |
OLOPATADINE 665 MCG NASAL SPRY |
4 |
Non-Preferred Drug |
45% | 45% | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2 |
Generic |
$8.00 | $24.00 | None |
OLUMIANT 2 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
4 |
Non-Preferred Drug |
45% | 45% | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
2 |
Generic |
$8.00 | $24.00 | Q:30 /30Days |
OMEPRAZOLE-BICARB 20-1,680 PKT PACKET [Zegerid] |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
OMEPRAZOLE-BICARB 40-1,680 PACKET [Zegerid] |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
ONDANSETRON 4 MG/5 ML SOLUTION |
2 |
Generic |
$8.00 | $24.00 | P Q:450 /30Days |
ONDANSETRON HCL 24 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | P Q:14 /28Days |
ONDANSETRON HCL 4 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | P |
ONDANSETRON HCL 8 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | P |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | P |
ONDANSETRON ODT 8 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | P |
ONFI 10 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 2.5 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | 33% | None |
ONFI 20 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
ONGLYZA 2.5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S |
ONGLYZA 5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENITRAM ER 0.25 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
ORFADIN 10 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 2 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 20 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 4 MG/ML SUSPENSION |
5 |
Specialty Tier |
33% | 33% | None |
ORFADIN 5 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ORILISSA 150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
ORILISSA 200 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | 33% | 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 |
33% | 33% | P Q:56 /28Days |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
5 |
Specialty Tier |
33% | 33% | P Q:56 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
ORSYTHIA-28 TABLET [Vienva] |
2 |
Generic |
$8.00 | $24.00 | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
2 |
Generic |
$8.00 | $24.00 | Q:1080 /365Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2 |
Generic |
$8.00 | $24.00 | Q:168 /365Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2 |
Generic |
$8.00 | $24.00 | Q:84 /365Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2 |
Generic |
$8.00 | $24.00 | Q:110 /365Days |
OSPHENA 60 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:30 /30Days |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
OXANDROLONE 10 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 2.5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days |
OXAPROZIN 600 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXCARBAZEPINE 150 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXCARBAZEPINE 300 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
45% | 45% | None |
OXCARBAZEPINE 600 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXERVATE 0.002% EYE DROPS |
5 |
Specialty Tier |
33% | 33% | P Q:56 /28Days |
OXICONAZOLE NITRATE 1% CREAM Cream (g) [Oxistat] |
4 |
Non-Preferred Drug |
45% | 45% | None |
OXISTAT 1% LOTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2 |
Generic |
$8.00 | $24.00 | None |
OXYBUTYNIN 5MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CL ER 10 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXYBUTYNIN CL ER 15 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXYBUTYNIN CL ER 5 MG TABLET |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODON-ACETAMINOPHEN 7.5-325 |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] |
4 |
Non-Preferred Drug |
45% | 45% | None |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2 |
Generic |
$8.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE-ACETAMINOPHEN 5-325 |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE-ASPIRIN 4.8355-325 |
2 |
Generic |
$8.00 | $24.00 | None |
OXYCODONE-IBUPROFEN 5-400 TAB |
2 |
Generic |
$8.00 | $24.00 | None |
oxymorphone hcl er 10 mg tab |
4 |
Non-Preferred Drug |
45% | 45% | None |
OXYMORPHONE HCL ER 15 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |
oxymorphone hcl er 20 mg tab |
4 |
Non-Preferred Drug |
45% | 45% | None |
oxymorphone hcl er 30 mg tab |
4 |
Non-Preferred Drug |
45% | 45% | None |
oxymorphone hcl er 40 mg tab |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxymorphone hcl er 5 mg tablet |
4 |
Non-Preferred Drug |
45% | 45% | None |
OXYMORPHONE HCL ER 7.5 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |