Drug List - O

O
Drug Name Tier Restrictions
OCELLA 28S 1*
OCTREOTIDE INJ 1
ODEFSEY 2
OFLOXACIN 1
OGESTREL 1
OLANZIPINE 1
OLM MED/HCTZ TAB 40-12.5 1
OLMESA MEDOX TAB 1
OLMESARTAN 1
OLMESARTAN/AMLODIPINE 1
OLMESARTAN/AMLODIPINE/HCTZ 1
OLMESARTAN/HCTZ 1
OLOPATADINE 0.1% 1
OLUX AER 3 Prior authorization, Quantity limit, Step therapy
OLYSIO 3 Prior authorization
OMEGA-3-ACID ETHYL ESTERS 1
OMEPRAZOLE NC
OMEPRAZOLE 2 MG/ML ORAL SUSPENSION (AGE RESTRICTION 4-12 YEARS OLD) 1
OMINTROPE 3 Prior authorization, Step therapy
OMNARIS SPR NC
OMNICEF 3 Prior authorization
OMNIFLEX DPR 3*
ONDANSETRON 1
ONE TOUCH TEST STRIPS 3 Prior authorization, Quantity limit
ONETOUCH 3 Prior authorization, Quantity limit
ONFI 3
ONGLYZA TAB 5MG 3 Step therapy
OPANA 3 Prior authorization
OPANA ER 3 Prior authorizaton
OPTIHALER MIS 3 Prior authorization
OPTIPRIO 3 Prior authorization
OPTIVAR DRO 3
ORACEA 3 Quantity limit
ORAPRED ODT TAB 2
ORAPRED SOL 15MG/5ML 3
ORENCIA 3 Prior authorization, Step therapy
ORPHENADRINE CITRATE ER 1
ORTHO DIAPHRAGM ALL-FLEX DRP KIT 3*
ORTHO EVRA DIS 24HR 3*
ORTHO TRI-CYCLEN 3 Prior authorization
ORTHO TRI-CYCLEN LO 3 Prior authorizaton
ORTHO-CEPT 28 3 Prior authorization
ORTHO-CYCLEN 3
ORTHO-NOVUM 3
ORTHOVISC INJ 3 Quantity limit, Step therapy
OSCIMIN SR TAB 0.375MG 1
OSCION CLEANSER 2 Quantity limit, Step therapy
OSELTAMIVIR 1 Quantity limit
OSENI TAB 25-30MG 3
OSMOPREP 2
OSPHENA 3 Step therapy
OTEZLA 3 Prior authorization, Step therapy
OTREXUP 3 Prior authorization, Step therapy
OVACE PLUS 3
OVCON-35 3 Prior authorization
OVIDE 2 Quantity limit
OVIDREL INJ UD 3
OXAPROZIN 1
OXAZEPAM 1
OXCARBAZEPINE 1
OXICONAZOLE CRE NITRATE 1 Prior authorizaton, Qunatity limit
OXISTAT 2 Prior authorization, Quantity limit
OXSORALEN LOT 1% 2 Prior authorization, Quantity limit
OXSORALEN ULTRA CAP 10MG 3 Prior authorization, Quantity limit
OXTELLAR XR TAB 600MG 3 Prior authorization
OXYBUTYNIN 1
OXYBUTYNIN ER 1
OXYCODONE HCL 1
OXYCODONE/ACETAMINOPHEN 1
OXYCONTIN 2
OXYMORPHONE TAB 1
OXYTROL 3