2024 Medicare Part D Plan Formulary Information |
RiverSpring Star (HMO I-SNP) (H6776-001-0)
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 RiverSpring Star (HMO I-SNP) (H6776-001-0) Formulary Drugs Starting with the Letter O in Bronx County, NY: CMS MA Region 3 which includes: NY
|
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 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OCALIVA 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OCELLA 3MG/0.03MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
OCTAGAM 10% VIAL |
1 |
Tier 1 |
25% | 25% | P |
OCTAGAM 5% VIAL |
1 |
Tier 1 |
25% | 25% | P |
OCTREOTIDE 1,000 MCG/5 ML VIAL [Sandostatin] |
1 |
Tier 1 |
25% | 25% | P |
OCTREOTIDE 1,000 MCG/ML VIAL [Sandostatin] |
1 |
Tier 1 |
25% | 25% | P |
OCTREOTIDE ACET 100 MCG/ML VIAL [Sandostatin] |
1 |
Tier 1 |
25% | 25% | P |
OCTREOTIDE ACET 50 MCG/ML VIAL [Sandostatin] |
1 |
Tier 1 |
25% | 25% | P |
OCTREOTIDE ACET 500 MCG/ML VL |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OCUFLOX 0.3% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT |
1 |
Tier 1 |
25% | 25% | None |
ODACTRA 12 SQ-HDM SUBLIGUAL TABLET |
1 |
Tier 1 |
25% | 25% | P |
ODEFSEY TABLET |
1 |
Tier 1 |
25% | 25% | None |
ODOMZO 200 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OFEV 100 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
OFEV 150 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
OFLOXACIN 0.3% EAR DROPS [Floxin] |
1 |
Tier 1 |
25% | 25% | None |
OFLOXACIN 0.3% EYE DROPS [Ocuflox] |
1 |
Tier 1 |
25% | 25% | None |
OFLOXACIN 300 MG TABLET [Floxin] |
1 |
Tier 1 |
25% | 25% | None |
OFLOXACIN 400 MG TABLET [Floxin] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OGSIVEO 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:180 /30Days |
OJJAARA 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OJJAARA 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OJJAARA 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OLANZAPINE 10 MG TABLET [Zyprexa] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE 10 MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
OLANZAPINE 15 MG TABLET [Zyprexa] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE 2.5 MG TABLET [Zyprexa] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE 20 MG TABLET [Zyprexa] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE 5 MG TABLET [Zyprexa] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE 7.5 MG TABLET [Zyprexa] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OLANZAPINE-FLUOXETINE 12-25 MG Capsule [Symbyax] |
1 |
Tier 1 |
25% | 25% | None |
OLANZAPINE-FLUOXETINE 12-50 MG Capsule [Symbyax] |
1 |
Tier 1 |
25% | 25% | None |
OLANZAPINE-FLUOXETINE 3-25 MG Capsule [Symbyax] |
1 |
Tier 1 |
25% | 25% | None |
OLANZAPINE-FLUOXETINE 6-25 MG Capsule [Symbyax] |
1 |
Tier 1 |
25% | 25% | None |
OLANZAPINE-FLUOXETINE 6-50 MG Capsule [Symbyax] |
1 |
Tier 1 |
25% | 25% | None |
OLMESARTAN MEDOXOMIL 20 MG TABLET [Benicar] |
1 |
Tier 1 |
25% | 25% | None |
OLMESARTAN MEDOXOMIL 40 MG TABLET [Benicar] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLMESARTAN MEDOXOMIL 5 MG TABLET [Benicar] |
1 |
Tier 1 |
25% | 25% | None |
OLMESARTAN-HCTZ 20-12.5 MG TABLET [Benicar HCT] |
1 |
Tier 1 |
25% | 25% | None |
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT] |
1 |
Tier 1 |
25% | 25% | None |
OLMESARTAN-HCTZ 40-25 MG TABLET [Benicar HCT] |
1 |
Tier 1 |
25% | 25% | None |
OLMSRTN-AMLDPN-HCTZ 20-5-12.5 TABLET [Tribenzor] |
1 |
Tier 1 |
25% | 25% | None |
OLMSRTN-AMLDPN-HCTZ 40-10-12.5 TABLET [Tribenzor] |
1 |
Tier 1 |
25% | 25% | None |
OLMSRTN-AMLDPN-HCTZ 40-10-25MG TABLET [Tribenzor] |
1 |
Tier 1 |
25% | 25% | None |
OLMSRTN-AMLDPN-HCTZ 40-5-12.5 TABLET [Tribenzor] |
1 |
Tier 1 |
25% | 25% | None |
OLMSRTN-AMLDPN-HCTZ 40-5-25 MG TABLET [Tribenzor] |
1 |
Tier 1 |
25% | 25% | None |
OLOPATADINE 665 MCG NASAL SPRY SPRAY/PUMP [Patanase] |
1 |
Tier 1 |
25% | 25% | Q:30.5 /30Days |
OLPRUVA 2 GRAM DOSE KIT PELET PACK |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLPRUVA 3 GRAM DOSE KIT PELET PACK |
1 |
Tier 1 |
25% | 25% | P |
OLPRUVA 4 GRAM DOSE KIT PELET PACK |
1 |
Tier 1 |
25% | 25% | P |
OLPRUVA 5 GRAM DOSE KIT PELET PACK |
1 |
Tier 1 |
25% | 25% | P |
OLPRUVA 6 GRAM DOSE KIT PELET PACK |
1 |
Tier 1 |
25% | 25% | P |
OLPRUVA 6.67 GRAM DOSE KIT PELET PACK |
1 |
Tier 1 |
25% | 25% | P |
OLUMIANT 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OLUMIANT 2 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OLUMIANT 4 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] |
1 |
Tier 1 |
25% | 25% | None |
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
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 |
Tier 1 |
25% | 25% | Q:60 /30Days |
OMEPRAZOLE-BICARB 20-1,100 CAPSULE [Zegerid] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OMEPRAZOLE-BICARB 20-1,680 PACKET [Zegerid] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OMEPRAZOLE-BICARB 40-1,100 CAPSULE [Zegerid] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OMEPRAZOLE-BICARB 40-1,680 PACKET [Zegerid] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OMNARIS 50 MCG NASAL SPRAY/PUMP |
1 |
Tier 1 |
25% | 25% | S Q:12.5 /30Days |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM |
1 |
Tier 1 |
25% | 25% | P |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG |
1 |
Tier 1 |
25% | 25% | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG |
1 |
Tier 1 |
25% | 25% | P |
OMVOH 100 MG/ML PEN INJECTOR |
1 |
Tier 1 |
25% | 25% | P Q:2 /28Days |
ONDANSETRON 4 MG/5 ML SOLUTION [Zofran Solution] |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONDANSETRON HCL 4 MG TABLET [Zofran] |
1 |
Tier 1 |
25% | 25% | P |
ONDANSETRON HCL 8 MG TABLET [Zofran] |
1 |
Tier 1 |
25% | 25% | P |
ONDANSETRON ODT 4 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ONDANSETRON ODT 8 MG TABLET RAPDIS [Zofran ODT] |
1 |
Tier 1 |
25% | 25% | P |
ONEXTON GEL PUMP |
1 |
Tier 1 |
25% | 25% | None |
ONFI 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
ONFI 2.5 MG/ML SUSPENSION |
1 |
Tier 1 |
25% | 25% | P Q:480 /30Days |
ONFI 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
ONGENTYS 25 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ONGENTYS 50 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ONUREG 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:14 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONUREG 300 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:14 /28Days |
ONZETRA XSAIL 11 MG/NOSEPIECE AER POW BA |
1 |
Tier 1 |
25% | 25% | Q:32 /28Days |
OPSUMIT 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
OPVEE 2.7 MG NASAL SPRAY |
1 |
Tier 1 |
25% | 25% | None |
OPZELURA 1.5% CREAM (G) |
1 |
Tier 1 |
25% | 25% | P Q:240 /28Days |
ORACEA CAPSULES 40MG 30 BOTTLE |
1 |
Tier 1 |
25% | 25% | S |
ORALAIR 300 IR SUBLINGUAL TABLET |
1 |
Tier 1 |
25% | 25% | None |
ORAPRED ODT 10 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
ORAPRED ODT 15 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
ORAPRED ODT 30 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
ORENCIA 125 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
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 |
Tier 1 |
25% | 25% | P Q:1.6 /28Days |
Orencia 4 SYRINGE, GLASS in 1 CARTON > 0.7 mL in 1 SYRINGE, GLASS |
1 |
Tier 1 |
25% | 25% | P Q:2.8 /28Days |
ORENCIA CLICKJECT 125 MG/ML |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Orenitram 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM ER 0.125 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM ER 0.25 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM ER 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM ER 2.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM MONTH 1 TITRATION KIT ER DSPK |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM MONTH 2 TITRATION KIT ER DSPK |
1 |
Tier 1 |
25% | 25% | P |
ORENITRAM MONTH 3 TITRATION KIT ER DSPK |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORFADIN 10 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ORFADIN 2 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ORFADIN 20 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ORFADIN 4 MG/ML SUSPENSION |
1 |
Tier 1 |
25% | 25% | P |
ORFADIN 5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ORGOVYX 120 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /28Days |
ORIAHNN 300-1-0.5MG/300MG CAPSULE SEQ |
1 |
Tier 1 |
25% | 25% | P |
ORILISSA 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ORILISSA 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ORKAMBI 100 MG-125 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:112 /28Days |
ORKAMBI 100-125 MG GRANULE PKT GRAN PACK |
1 |
Tier 1 |
25% | 25% | P Q:56 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK |
1 |
Tier 1 |
25% | 25% | P Q:56 /28Days |
ORKAMBI 200 MG-125 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:112 /28Days |
ORKAMBI 75-94 MG GRANULE PACK |
1 |
Tier 1 |
25% | 25% | P Q:56 /28Days |
ORLADEYO 110 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ORLADEYO 150 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ORSERDU 345 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ORSERDU 86 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OSELTAMIVIR 6 MG/ML ORAL SUSPENSION [Tamiflu] |
1 |
Tier 1 |
25% | 25% | None |
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] |
1 |
Tier 1 |
25% | 25% | None |
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu] |
1 |
Tier 1 |
25% | 25% | None |
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OSENI 12.5-30 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OSENI 25-15 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OSENI 25-30 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OSENI 25-45 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
OSMOLEX ER 129 MG TABLET BP 24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OSMOLEX ER 193 MG TABLET BP 24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
OSPHENA 60 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
OTEZLA 28 DAY STARTER PACK TABLET DS PK |
1 |
Tier 1 |
25% | 25% | P Q:55 /180Days |
OTEZLA 30 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
OTOVEL 0.3%-0.025% EAR DROPS VIAL |
1 |
Tier 1 |
25% | 25% | None |
OTREXUP 10 MG/0.4 ML AUTO-INJ |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OTREXUP 12.5 MG/0.4 ML AUTOINJ |
1 |
Tier 1 |
25% | 25% | None |
OTREXUP 15 MG/0.4 ML AUTO-INJ |
1 |
Tier 1 |
25% | 25% | None |
OTREXUP 17.5 MG/0.4 ML AUTOINJ |
1 |
Tier 1 |
25% | 25% | None |
OTREXUP 20 MG/0.4 ML AUTO-INJ |
1 |
Tier 1 |
25% | 25% | None |
OTREXUP 22.5 MG/0.4 ML AUTOINJ |
1 |
Tier 1 |
25% | 25% | None |
OTREXUP 25 MG/0.4 ML AUTO-INJ |
1 |
Tier 1 |
25% | 25% | None |
OVIDE 0.5% LOTION |
1 |
Tier 1 |
25% | 25% | None |
OXACILLIN 1 GM VIAL |
1 |
Tier 1 |
25% | 25% | P |
OXACILLIN 10 GM VIAL |
1 |
Tier 1 |
25% | 25% | P |
OXACILLIN 1GM/50ML INJ |
1 |
Tier 1 |
25% | 25% | P |
OXACILLIN 2 GM VIAL |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXACILLIN 2GM/50ML INJ |
1 |
Tier 1 |
25% | 25% | P |
OXAPROZIN 600 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
OXBRYTA 300 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:150 /30Days |
OXBRYTA 300 MG TABLET FOR SUSP |
1 |
Tier 1 |
25% | 25% | P Q:150 /30Days |
OXBRYTA 500 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXCARBAZEPINE 150 MG TABLET [Trileptal] |
1 |
Tier 1 |
25% | 25% | None |
OXCARBAZEPINE 300 MG TABLET [Trileptal] |
1 |
Tier 1 |
25% | 25% | None |
OXCARBAZEPINE 300 MG/5 ML SUSP |
1 |
Tier 1 |
25% | 25% | None |
OXCARBAZEPINE 600 MG TABLET [Trileptal] |
1 |
Tier 1 |
25% | 25% | None |
OXERVATE 0.002% EYE DROPS |
1 |
Tier 1 |
25% | 25% | P |
OXICONAZOLE NITRATE 1% CREAM (g) [Oxistat] |
1 |
Tier 1 |
25% | 25% | Q:90 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXISTAT 1% CREAM (g) |
1 |
Tier 1 |
25% | 25% | Q:90 /28Days |
OXISTAT 1% LOTION |
1 |
Tier 1 |
25% | 25% | Q:60 /28Days |
OXTELLAR XR 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
OXTELLAR XR 300 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
OXTELLAR XR 600 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
OXYBUTYNIN 5 MG TABLET [Ditropan] |
1 |
Tier 1 |
25% | 25% | None |
OXYBUTYNIN 5 MG/5 ML SYRUP [Ditropan] |
1 |
Tier 1 |
25% | 25% | None |
OXYBUTYNIN CL ER 10 MG TABLET 24 [Ditropan XL] |
1 |
Tier 1 |
25% | 25% | None |
OXYBUTYNIN CL ER 15 MG TABLET ER 24 [Ditropan XL] |
1 |
Tier 1 |
25% | 25% | None |
OXYBUTYNIN CL ER 5 MG TABLET ER 24 [Ditropan XL] |
1 |
Tier 1 |
25% | 25% | None |
OXYCODONE HCL (IR) 20 MG TABLET [Roxicodone] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL (IR) 5 MG TABLET [Roxybond] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
OXYCODONE HCL 10 MG TABLET [Dazidox] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
OXYCODONE HCL 100 MG/5 ML ORAL CONC [Roxicodone] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
OXYCODONE HCL 15 MG TABLET [Roxybond] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
OXYCODONE HCL 30 MG TABLET [Roxybond] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
OXYCODONE HCL 5 MG CAPSULE [OxyIR] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
OXYCODONE HCL 5 MG/5 ML SOLUTION [Roxicodone] |
1 |
Tier 1 |
25% | 25% | Q:1200 /30Days |
OXYCODONE HCL ER 10 MG TABLET 12H [OxyContin] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYCODONE HCL ER 20 MG TABLET 12H [OxyContin] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYCODONE-ACETAMINOPHEN 10-300 TABLET [Prolate] |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE-ACETAMINOPHEN 5-300 TABLET [Prolate] |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325 TABLET [Roxicet] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
OXYCODONE-ACETAMINOPHEN 5-325/5 SOLUTION [Roxicet] |
1 |
Tier 1 |
25% | 25% | Q:1860 /30Days |
OXYCODONE-ACETAMINOPHEN 7.5-300 TABLET [Prolate] |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
OXYCODONE-ACETAMINOPHN 2.5-325 TABLET [Percocet] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
OXYCODONE-ACETAMINOPHN 7.5-325 TABLET [Percocet] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
OxyContin 10mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OxyContin 15mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OxyContin 20mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OxyContin 30mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OxyContin 40mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OxyContin 60mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OxyContin 80mg/1 |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
OXYMORPHONE HCL 10 MG TABLET [Opana] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
OXYMORPHONE HCL 5 MG TABLET [Opana] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
OXYMORPHONE HCL ER 10 MG TABLET ER 12H |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYMORPHONE HCL ER 15 MG TABLET ER 12H |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYMORPHONE HCL ER 20 MG TABLET ER 12H [Opana] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYMORPHONE HCL ER 30 MG TABLET 12H [Opana ER] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYMORPHONE HCL ER 40 MG TABLET ER 12H [Opana] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYMORPHONE HCL ER 5 MG TABLET ER 12H [Opana] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
OXYMORPHONE HCL ER 7.5 MG TABLET ER 12H [Opana] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYTROL 3.9 MG/24HR PATCH TDSW |
1 |
Tier 1 |
25% | 25% | Q:8 /28Days |
OZEMPIC 0.25-0.5 MG/DOSE PEN PEN INJCTR |
1 |
Tier 1 |
25% | 25% | P Q:3 /28Days |
OZEMPIC 1 MG/DOSE (4 MG/3 ML) PEN INJECTOR |
1 |
Tier 1 |
25% | 25% | P Q:3 /28Days |
OZEMPIC 2 MG/DOSE (8 MG/3 ML) PEN INJCTR |
1 |
Tier 1 |
25% | 25% | P Q:3 /28Days |
OZOBAX DS 10 MG/5 ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |