2024 Medicare Part D Plan Formulary Information |
Security Blue HMO-POS Standard (HMO-POS) (H3957-045-2)
Benefits & Contact Info
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Security Blue HMO-POS Standard (HMO-POS) (H3957-045-2) Formulary Drugs Starting with the Letter O in Cameron County, PA: CMS MA Region 6 which includes: PA
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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 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OCALIVA 5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OCTAGAM 10% VIAL |
5 |
Tier 5 |
33% | N/A | P |
OCTAGAM 5% VIAL |
5 |
Tier 5 |
33% | N/A | P |
OCTREOTIDE 1,000 MCG/5 ML VIAL [Sandostatin] |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OCTREOTIDE 1,000 MCG/ML VIAL [Sandostatin] |
3 |
Preferred Brand |
$44.00 | $110.00 | P |
OCTREOTIDE ACET 100 MCG/ML VIAL [Sandostatin] |
2 |
Generic |
$13.00 | $32.50 | P |
OCTREOTIDE ACET 50 MCG/ML VIAL [Sandostatin] |
2 |
Generic |
$13.00 | $32.50 | P |
OCTREOTIDE ACET 500 MCG/ML VL |
5 |
Tier 5 |
33% | N/A | P |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
2 |
Generic |
$13.00 | $32.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODACTRA 12 SQ-HDM SUBLIGUAL TABLET |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
ODEFSEY TABLET |
5 |
Tier 5 |
33% | N/A | Q:31 /31Days |
ODOMZO 200 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OFEV 100 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
OFEV 150 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
OFLOXACIN 0.3% EAR DROPS [Floxin] |
2 |
Generic |
$13.00 | $32.50 | None |
OFLOXACIN 0.3% EYE DROPS [Ocuflox] |
2 |
Generic |
$13.00 | $32.50 | None |
OFLOXACIN 300 MG TABLET [Floxin] |
2 |
Generic |
$13.00 | $32.50 | None |
OFLOXACIN 400 MG TABLET [Floxin] |
2 |
Generic |
$13.00 | $32.50 | None |
OGSIVEO 50 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:186 /31Days |
OJJAARA 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OJJAARA 150 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OJJAARA 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OLANZAPINE 10 MG TABLET [Zyprexa] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE 10 MG VIAL |
2 |
Generic |
$13.00 | $32.50 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
2 |
Generic |
$13.00 | $32.50 | None |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
2 |
Generic |
$13.00 | $32.50 | None |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
2 |
Generic |
$13.00 | $32.50 | None |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
2 |
Generic |
$13.00 | $32.50 | None |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
2 |
Generic |
$13.00 | $32.50 | None |
OLMESARTAN MEDOXOMIL 20 MG TABLET [Benicar] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLMESARTAN MEDOXOMIL 40 MG TABLET [Benicar] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLMESARTAN MEDOXOMIL 5 MG TABLET [Benicar] |
2 |
Generic |
$13.00 | $32.50 | Q:93 /31Days |
OLMESARTAN-HCTZ 20-12.5 MG TABLET [Benicar HCT] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
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 |
$13.00 | $32.50 | Q:31 /31Days |
OLMESARTAN-HCTZ 40-25 MG TABLET [Benicar HCT] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OLMSRTN-AMLDPN-HCTZ 20-5-12.5 TABLET [Tribenzor] |
3 |
Preferred Brand |
$44.00 | $110.00 | None |
OLMSRTN-AMLDPN-HCTZ 40-10-12.5 TABLET [Tribenzor] |
3 |
Preferred Brand |
$44.00 | $110.00 | None |
OLMSRTN-AMLDPN-HCTZ 40-10-25MG TABLET [Tribenzor] |
3 |
Preferred Brand |
$44.00 | $110.00 | None |
OLMSRTN-AMLDPN-HCTZ 40-5-12.5 TABLET [Tribenzor] |
3 |
Preferred Brand |
$44.00 | $110.00 | None |
OLMSRTN-AMLDPN-HCTZ 40-5-25 MG TABLET [Tribenzor] |
3 |
Preferred Brand |
$44.00 | $110.00 | None |
OLOPATADINE 665 MCG NASAL SPRY SPRAY/PUMP [Patanase] |
2 |
Generic |
$13.00 | $32.50 | Q:30.5 /30Days |
OLUMIANT 1 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OLUMIANT 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
OLUMIANT 4 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
3 |
Preferred Brand |
$44.00 | $110.00 | Q:124 /31Days |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
5 |
Tier 5 |
33% | N/A | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
5 |
Tier 5 |
33% | N/A | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
ONDANSETRON 4 MG/5 ML SOLUTION [Zofran Solution] |
2 |
Generic |
$13.00 | $32.50 | P |
ONDANSETRON HCL 4 MG TABLET [Zofran] |
2 |
Generic |
$13.00 | $32.50 | P |
ONDANSETRON HCL 8 MG TABLET [Zofran] |
2 |
Generic |
$13.00 | $32.50 | P |
ONDANSETRON ODT 4 MG TABLET |
2 |
Generic |
$13.00 | $32.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON ODT 8 MG TABLET RAPDIS [Zofran ODT] |
2 |
Generic |
$13.00 | $32.50 | P |
ONGENTYS 25 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P Q:31 /31Days |
ONGENTYS 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P Q:31 /31Days |
ONUREG 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:14 /28Days |
ONUREG 300 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:14 /28Days |
ONZETRA XSAIL 11 MG/NOSEPIECE AER POW BA |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:16 /28Days |
OPSUMIT 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
ORALAIR 300 IR SUBLINGUAL TABLET |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
ORENCIA 125 MG/ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P Q:4 /28Days |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.4 mL in 1 SYRINGE, GLASS |
5 |
Tier 5 |
33% | N/A | P Q:1.6 /28Days |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
5 |
Tier 5 |
33% | N/A | P Q:2.8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORENCIA CLICKJECT 125 MG/ML |
5 |
Tier 5 |
33% | N/A | P Q:4 /28Days |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
5 |
Tier 5 |
33% | N/A | P Q:261 /31Days |
ORENITRAM ER 0.125 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P Q:93 /31Days |
ORENITRAM ER 0.25 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:186 /31Days |
ORENITRAM ER 1 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:186 /31Days |
ORENITRAM ER 2.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:521 /31Days |
ORGOVYX 120 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
ORIAHNN 300-1-0.5MG/300MG CAPSULE SEQ |
5 |
Tier 5 |
33% | N/A | P Q:56 /28Days |
ORILISSA 150 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
ORILISSA 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
ORKAMBI 100 MG-125 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:124 /31Days |
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 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
5 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
ORKAMBI 200 MG-125 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:124 /31Days |
ORKAMBI 75-94 MG GRANULE PACK |
5 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
ORLADEYO 110 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
ORLADEYO 150 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
ORSERDU 345 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:31 /31Days |
ORSERDU 86 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:93 /31Days |
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION [Tamiflu] |
3 |
Preferred Brand |
$44.00 | $110.00 | Q:1080 /365Days |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
2 |
Generic |
$13.00 | $32.50 | Q:170 /365Days |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
2 |
Generic |
$13.00 | $32.50 | Q:90 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
2 |
Generic |
$13.00 | $32.50 | Q:90 /365Days |
OTEZLA 28 DAY STARTER PACK TABLET DS PK |
5 |
Tier 5 |
33% | N/A | P Q:55 /28Days |
OTEZLA 30 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:62 /31Days |
OTOVEL 0.3%-0.025% EAR DROPS VIAL |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OTREXUP 12.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN 1 GM VIAL |
2 |
Generic |
$13.00 | $32.50 | None |
OXACILLIN 10 GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None |
OXACILLIN 1GM/50ML INJ |
2 |
Generic |
$13.00 | $32.50 | None |
OXACILLIN 2 GM VIAL |
2 |
Generic |
$13.00 | $32.50 | None |
OXAPROZIN 600 MG TABLET |
2 |
Generic |
$13.00 | $32.50 | None |
OXAZEPAM 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OXAZEPAM 15 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OXAZEPAM 30 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P |
OXBRYTA 300 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:248 /31Days |
OXBRYTA 300 MG TABLET FOR SUSP |
5 |
Tier 5 |
33% | N/A | P Q:248 /31Days |
OXBRYTA 500 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:155 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXCARBAZEPINE 150 MG TABLET [Trileptal] |
2 |
Generic |
$13.00 | $32.50 | None |
OXCARBAZEPINE 300 MG TABLET [Trileptal] |
2 |
Generic |
$13.00 | $32.50 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
2 |
Generic |
$13.00 | $32.50 | None |
OXCARBAZEPINE 600 MG TABLET [Trileptal] |
2 |
Generic |
$13.00 | $32.50 | None |
OXERVATE 0.002% EYE DROPS |
5 |
Tier 5 |
33% | N/A | P Q:112 /56Days |
OXISTAT 1% LOTION |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | S Q:60 /28Days |
OXTELLAR XR 150 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None |
OXTELLAR XR 300 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None |
OXTELLAR XR 600 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
OXYBUTYNIN 5 MG TABLET [Ditropan] |
2 |
Generic |
$13.00 | $32.50 | None |
OXYBUTYNIN 5 MG/5 ML SYRUP [Ditropan] |
2 |
Generic |
$13.00 | $32.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYBUTYNIN CL ER 10 MG TABLET 24 [Ditropan XL] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OXYBUTYNIN CL ER 15 MG TABLET ER 24 [Ditropan XL] |
3 |
Preferred Brand |
$44.00 | $110.00 | Q:62 /31Days |
OXYBUTYNIN CL ER 5 MG TABLET ER 24 [Ditropan XL] |
2 |
Generic |
$13.00 | $32.50 | Q:31 /31Days |
OXYCODONE HCL (IR) 20 MG TABLET [Roxicodone] |
2 |
Generic |
$13.00 | $32.50 | P Q:186 /31Days |
OXYCODONE HCL (IR) 5 MG TABLET [Roxybond] |
2 |
Generic |
$13.00 | $32.50 | P Q:186 /31Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
2 |
Generic |
$13.00 | $32.50 | P Q:186 /31Days |
OXYCODONE HCL 100 MG/5 ML ORAL CONC [Roxicodone] |
2 |
Generic |
$13.00 | $32.50 | P Q:180 /31Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
2 |
Generic |
$13.00 | $32.50 | P Q:186 /31Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
3 |
Preferred Brand |
$44.00 | $110.00 | P Q:138 /31Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
2 |
Generic |
$13.00 | $32.50 | P Q:186 /31Days |
OXYCODONE HCL 5 MG/5 ML SOLUTION [Roxicodone] |
2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
3 |
Preferred Brand |
$44.00 | $110.00 | P Q:372 /31Days |
OXYCODONE-ACETAMINOPHEN 5-325 TABLET [Roxicet] |
2 |
Generic |
$13.00 | $32.50 | P Q:372 /31Days |
OXYCODONE-ACETAMINOPHN 2.5-325 TABLET [Percocet] |
3 |
Preferred Brand |
$44.00 | $110.00 | P Q:372 /31Days |
OXYCODONE-ACETAMINOPHN 7.5-325 TABLET [Percocet] |
2 |
Generic |
$13.00 | $32.50 | P Q:372 /31Days |
OXYTROL 3.9 MG/24HR PATCH TDSW |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:8 /28Days |
OZEMPIC 0.25-0.5 MG/DOSE PEN PEN INJCTR |
3 |
Preferred Brand |
$44.00 | $110.00 | P Q:3 /28Days |
OZEMPIC 1 MG/DOSE (4 MG/3 ML) PEN INJECTOR |
3 |
Preferred Brand |
$44.00 | $110.00 | P Q:3 /28Days |
OZEMPIC 2 MG/DOSE (8 MG/3 ML) PEN INJCTR |
3 |
Preferred Brand |
$44.00 | $110.00 | P Q:3 /28Days |