2019 Medicare Part D Plan Formulary Information |
SeniorCare Complete (HMO SNP) (H2419-001-0)
Benefit Details
|
The SeniorCare Complete (HMO SNP) (H2419-001-0) Formulary Drugs Starting with the Letter O in Sibley County, MN: CMS MA Region 19 which includes: MN Plan Monthly Premium: $25.50 Deductible: $415 |
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 |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCALIVA 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCELLA 3MG/0.03MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OCTREOTIDE 1,000 MCG/ML VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCTREOTIDE ACET 0.05 MG/ML VL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCTREOTIDE ACET 100 MCG/ML VL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCTREOTIDE ACET 200 MCG/ML VL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCTREOTIDE ACET 500 MCG/ML VL |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ODEFSEY TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODOMZO 200 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OFEV 100 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OFEV 150 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OFLOXACIN 0.3 % DRP |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OFLOXACIN 0.3% EAR DROPS |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OFLOXACIN 300 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OFLOXACIN 400 MG TABLET [Floxin] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 10 MG VIAL |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:90 /30Days |
OLANZAPINE 15 MG TABLET [Zyprexa] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
1 |
All Formulary Drugs |
$0.00 | N/A | 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] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OLMESARTAN-HCTZ 20-12.5 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OLMESARTAN-HCTZ 40-25 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OLOPATADINE HCL 0.1% EYE DROPS |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OMEGA-3 ETHYL ESTERS 1 GM CAP [Lovaza] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ONDANSETRON 4 MG/5 ML SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ONDANSETRON HCL 24 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ONDANSETRON HCL 4 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ONDANSETRON HCL 8 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ONDANSETRON ODT 4 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ONDANSETRON ODT 8 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORENCIA 125 MG/ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORENCIA CLICKJECT 125 MG/ML |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORFADIN 10 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORFADIN 2 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORFADIN 20 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORFADIN 4 MG/ML SUSPENSION |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORFADIN 5 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORILISSA 150 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORILISSA 200 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORKAMBI 100 MG-125 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
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 |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORKAMBI 200 MG-125 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORPHENADRINE ER 100 MG TABLET [Norflex] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ORSYTHIA-28 TABLET [Vienva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:540 /180Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:84 /180Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:42 /180Days |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:42 /180Days |
OTEZLA 28 DAY STARTER PACK |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OTEZLA 30 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 10 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXANDROLONE 2.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXCARBAZEPINE 150 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXCARBAZEPINE 300 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXCARBAZEPINE 600 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXERVATE 0.002% EYE DROPS |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYBUTYNIN 5 MG/5 ML SYRUP |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYBUTYNIN 5MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYBUTYNIN CL ER 10 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYBUTYNIN CL ER 15 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CL ER 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYCODON-ACETAMINOPHEN 2.5-325 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYCODON-ACETAMINOPHEN 7.5-325 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:120 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:5400 /30Days |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYCODONE HCL ER 80 MG TABLET 12H [OxyContin] |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYCODONE-ACETAMINOPHEN 5-325 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYCODONE-ASPIRIN 4.8355-325 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OXYCODONE-IBUPROFEN 5-400 TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
OZEMPIC 0.25-0.5 MG DOSE PEN |
1 |
All Formulary Drugs |
$0.00 | N/A | S Q:3 /28Days |
OZEMPIC 1 MG DOSE PEN |
1 |
All Formulary Drugs |
$0.00 | N/A | S Q:3 /28Days |