2021 Medicare Part D Plan Formulary Information |
Spirit Rx (HMO-POS) (H5211-004-0)
Benefit Details
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below. |
The Spirit Rx (HMO-POS) (H5211-004-0) Formulary Drugs Starting with the Letter O in Polk County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $226.00 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 |
OCELLA 3MG/0.03MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OCTAGAM 10% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OCTAGAM 5% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
OCTREOTIDE 1,000 MCG/ML VIAL [Sandostatin] |
5 |
Specialty Tier |
33% | N/A | P |
OCTREOTIDE ACET 0.05 MG/ML VL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACET 100 MCG/ML VIAL [Sandostatin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACET 200 MCG/ML VIAL [Sandostatin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Specialty Tier |
33% | N/A | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2 |
Generic |
$20.00 | $60.00 | None |
ODEFSEY TABLET |
5 |
Specialty Tier |
33% | 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 |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
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 |
$20.00 | $60.00 | None |
OFLOXACIN 0.3% EAR DROPS [Floxin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OFLOXACIN 300 MG TABLET [Floxin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OFLOXACIN 400 MG TABLET [Floxin] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OLANZAPINE 10 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /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 |
$20.00 | $60.00 | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
OLMESARTAN MEDOXOMIL 20 MG TABLET [Benicar] |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 40 MG TABLET [Benicar] |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
OLMESARTAN MEDOXOMIL 5 MG TABLET [Benicar] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OLMESARTAN-HCTZ 20-12.5 MG TABLET [Benicar HCT] |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
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] |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
OLMESARTAN-HCTZ 40-25 MG TABLET [Benicar HCT] |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
OLMSRTN-AMLDPN-HCTZ 20-5-12.5 TABLET [Tribenzor] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMSRTN-AMLDPN-HCTZ 40-10-12.5 TABLET [Tribenzor] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMSRTN-AMLDPN-HCTZ 40-10-25MG TABLET [Tribenzor] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMSRTN-AMLDPN-HCTZ 40-5-12.5 TABLET [Tribenzor] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLMSRTN-AMLDPN-HCTZ 40-5-25 MG TABLET [Tribenzor] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
OLOPATADINE 665 MCG NASAL SPRY SPRAY/PUMP [Patanase] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:31 /30Days |
OLOPATADINE HCL 0.1% EYE DROPS |
2 |
Generic |
$20.00 | $60.00 | None |
OLOPATADINE HCL 0.2% EYE DROPS [Pataday] |
2 |
Generic |
$20.00 | $60.00 | None |
OLUMIANT 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLUMIANT 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:90 /30Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days |
ONDANSETRON 4 MG/5 ML SOLUTION [Zofran] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:450 /30Days |
ONDANSETRON HCL 24 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days |
ONDANSETRON HCL 4 MG TABLET [Zofran] |
2 |
Generic |
$20.00 | $60.00 | P Q:90 /30Days |
ONDANSETRON HCL 8 MG TABLET [Zofran] |
2 |
Generic |
$20.00 | $60.00 | P Q:90 /30Days |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | P Q:90 /30Days |
ONDANSETRON ODT 8 MG TABLET RAPDIS [Zofran ODT] |
2 |
Generic |
$20.00 | $60.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONGENTYS 25 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
ONGENTYS 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
ONUREG 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:14 /28Days |
ONUREG 300 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:14 /28Days |
OPSUMIT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ORENCIA 125 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | P |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | P |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Specialty Tier |
33% | N/A | P |
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 |
$100.00 | $300.00 | 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% | N/A | P |
ORENITRAM ER 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 2.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ORGOVYX 120 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:32 /30Days |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:112 /28Days |
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 |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:112 /28Days |
ORLADEYO 110 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ORLADEYO 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ORPHENADRINE ER 100 MG TABLET [Norflex] |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORSYTHIA-28 TABLET [Vienva] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2 |
Generic |
$20.00 | $60.00 | None |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2 |
Generic |
$20.00 | $60.00 | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2 |
Generic |
$20.00 | $60.00 | None |
OTEZLA 28 DAY STARTER PACK TAB DS PK |
5 |
Specialty Tier |
33% | N/A | P Q:55 /28Days |
OTEZLA 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
OXACILLIN 1 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXACILLIN 10 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXACILLIN 1GM/50ML INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXACILLIN 2 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN 2GM/50ML INJ |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXANDROLONE 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
OXANDROLONE 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:120 /30Days |
OXAPROZIN 600 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXAZEPAM 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXAZEPAM 15 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXAZEPAM 30 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXCARBAZEPINE 150 MG TABLET [Trileptal] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXCARBAZEPINE 300 MG TABLET [Trileptal] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXCARBAZEPINE 600 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN 5 MG TABLET [Ditropan] |
2 |
Generic |
$20.00 | $60.00 | None |
OXYBUTYNIN 5 MG/5 ML SYRUP |
2 |
Generic |
$20.00 | $60.00 | None |
OXYBUTYNIN CL ER 10 MG TABLET ER 24 [Ditropan XL] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OXYBUTYNIN CL ER 15 MG TABLET ER 24 [Ditropan XL] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OXYBUTYNIN CL ER 5 MG TABLET ER 24 [Ditropan XL] |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
OXYCODON-ACETAMINOPHEN 7.5-325 TABLET [Percocet] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days |
OXYCODONE HCL 100 MG/5 ML ORAL CONC [Roxicodone] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:240 /30Days |
OXYCODONE HCL 20 MG TABLET [Roxicodone] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 5 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLUTION [Roxicodone] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:3900 /30Days |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE HCL ER 15 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE HCL ER 30 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE HCL ER 40 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE HCL ER 60 MG TABLET 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE HCL ER 80 MG TABLET ER 12H [OxyContin] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 TABLET [Roxicet] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-ACETAMINOPHN 2.5-325 TABLET [Percocet] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days |
OxyContin 10mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OxyContin 15mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OxyContin 20mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OxyContin 30mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OxyContin 40mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OxyContin 60mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OxyContin 80mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL 10 MG TABLET [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL 5 MG TABLET [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL ER 10 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYMORPHONE HCL ER 15 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL ER 20 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL ER 30 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL ER 40 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL ER 5 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OXYMORPHONE HCL ER 7.5 MG TABLET ER 12H [Opana] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
OZEMPIC 0.25-0.5 MG DOSE PEN |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days |
OZEMPIC 1 MG DOSE PEN |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:3 /28Days |
OZEMPIC 1 MG/DOSE (4 MG/3 ML) PEN INJECTOR |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:3 /28Days |