Drug - Brand Name (Generic Name) PA Status Class Drug Notes Opvee (nalmefene) - PA PA ALCOHOL AND DRUG CESSATION AGENT Odactra (house dust mite allergen extract) - PA PA ALLERGENS Oralair (grass pollen allergen extract) - PA PA ALLERGENS oxandrolone - PA PA ANABOLIC STEROID ofloxacin tablet A90 - PA PA ANTIBIOTICS A90 omadacycline injection - PA PA ANTIBIOTICS omadacycline tablet - PA PA ANTIBIOTICS Orbactiv (oritavancin) - PA PA ANTIBIOTICS oritavancin - PA PA ANTIBIOTICS oxacillin ANTIBIOTICS ozenoxacin - PA PA ANTIBIOTICS "Onfi # (clobazam suspension, tablet)" ANTICONVULSANTS # oxcarbazepine extended-release - PA; See Table 20; See Table 71 PA ANTICONVULSANTS "oxcarbazepine suspension BP, A90 - PA < 6 years; See Table 20; See Table 71" PA ANTICONVULSANTS "BP, A90" oxcarbazepine tablet A90 - PA < 6 years; See Table 20; See Table 71 PA ANTICONVULSANTS "A90, #" Oxtellar XR (oxcarbazepine extended-release) - PA; See Table 20; See Table 71 PA ANTICONVULSANTS olanzapine / fluoxetine A90 - PA; See Table 17; See Table 24; See Table 71 PA ANTIDEPRESSANTS A90 opium tincture - PA PA ANTIDIARRHEALS ondansetron 24 mg tablet A90 - PA PA ANTIEMETICS A90 "ondansetron 4 mg, 8 mg tablet A90" ANTIEMETICS "A90, #" ondansetron injection ANTIEMETICS ondansetron orally disintegrating tablet A90 ANTIEMETICS A90 ondansetron solution A90 - PA PA ANTIEMETICS A90 "Obizur (antihemophilic factor, recombinant, porcine sequence-Obizur)" ANTI-HEMOPHILIA AGENTS olopatadine ophthalmic solution A90 ANTIHISTAMINES A90 Orserdu (elacestrant) - PA PA ANTINEOPLASTICS "orlistat BP, A90 - PA" PA ANTI-OBESITY AGENTS "BP, A90" Ovide (malathion) A90 - PA PA ANTIPARASITICS A90 Ongentys (opicapone) - PA PA ANTIPARKINSON opicapone - PA PA ANTIPARKINSON Osmolex ER (amantadine extended-release tablet) - PA PA ANTIPARKINSON olanzapine / samidorphan - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC olanzapine 15 mg orally disintegrating tablet A90 - PA 2 units/day; See Table 24; See Table 71 PA 2 units/day ANTIPSYCHOTIC "A90, #" "olanzapine 210 mg, 300 mg extended-release injection - PA 2 injections/28 days; See Table 24; See Table 71" PA 2 injections/28 days ANTIPSYCHOTIC olanzapine 405 mg extended-release injection - PA 1 injection/28 days; See Table 24; See Table 71 PA 1 injection/28 days ANTIPSYCHOTIC "olanzapine 5 mg, 10 mg, 20 mg orally disintegrating tablet A90 - PA 1 unit/day; See Table 24; See Table 71" PA 1 unit/day ANTIPSYCHOTIC "A90, #" olanzapine injection ANTIPSYCHOTIC # olanzapine tablet A90 - PA 2 units/day; See Table 24; See Table 71 PA 2 units/day ANTIPSYCHOTIC "A90, #" Orap # (pimozide) A90 - PA < 6 years; See Table 24; See Table 71 PA ANTIPSYCHOTIC "A90, #" omeprazole / sodium bicarbonate capsule M90 ANTI-ULCER PREPARATIONS "M90, #" omeprazole / sodium bicarbonate powder for oral suspension M90 - PA PA ANTI-ULCER PREPARATIONS M90 omeprazole / sodium bicarbonate suspension - PA PA ANTI-ULCER PREPARATIONS Odefsey (emtricitabine / rilpivirine / tenofovir alafenamide) PD ANTIVIRALS PD ombitasvir / paritaprevir / ritonavir / dasabuvir - PA PA ANTIVIRALS oseltamivir 30mg - PA > 20 units/ claim and PA > 40 units/ 365 days PA > 20 units/ claim and PA > 40 units/ 365 days ANTIVIRALS # oseltamivir 45 mg and 75 mg - PA > 10 units/ claim and PA > 20 units/ 365 days PA > 10 units/ claim and PA > 20 units/ 365 days ANTIVIRALS # oseltamivir suspension - PA > 180 mL/ claim and PA > 360 mL/ 365 days PA > 180 mL/ claim and PA > 360 mL/ 365 days ANTIVIRALS # oxazepam - PA; See Table 69; See Table 71 PA BENZODIAZEPINES obeticholic acid - PA PA BILE THERAPY Ocaliva (obeticholic acid) - PA PA BILE THERAPY odevixibat - PA PA BILE THERAPY "Octagam (immune globulin IV, human-Octagam) - PA" PA BIOLOGICAL omalizumab - PA PA BIOLOGICAL onabotulinumtoxinA - PA PA BIOLOGICAL olodaterol - PA PA BRONCHODILATORS olmesartan / hydrochlorothiazide M90 CARDIOVASCULAR "M90, #" olmesartan M90 CARDIOVASCULAR "M90, #" Opsumit (macitentan) - PA PA CARDIOVASCULAR Orenitram (treprostinil tablet) - PA PA CARDIOVASCULAR obinutuzumab MB - PA PA CHEMOTHERAPY MB Odomzo (sonidegib) - PA PA CHEMOTHERAPY ofatumumab vial MB - PA PA CHEMOTHERAPY MB Ogivri (trastuzumab-dkst) MB - PA PA CHEMOTHERAPY MB olaparib - PA PA CHEMOTHERAPY olutasidenib - PA PA CHEMOTHERAPY omacetaxine mepesuccinate - PA PA CHEMOTHERAPY Oncaspar (pegaspargase) MB CHEMOTHERAPY MB Onivyde (irinotecan liposome) MB - PA PA CHEMOTHERAPY MB Ontruzant (trastuzumab-dttb) MB - PA PA CHEMOTHERAPY MB Onureg (azacitidine tablet) - PA PA CHEMOTHERAPY Opdivo (nivolumab) MB - PA PA CHEMOTHERAPY MB Opdualag (nivolumab / relatlimab-rmbw) MB - PA PA CHEMOTHERAPY MB osimertinib - PA PA CHEMOTHERAPY oxaliplatin MB CHEMOTHERAPY MB Ora-Plus suspending vehicle * COMPOUNDING AGENT * Ora-Sweet oral syrup * COMPOUNDING AGENT * Ora-Sweet-SF oral syrup * COMPOUNDING AGENT * Ortho Micronor # (norethindrone 0.35 mg) M90 CONTRACEPTIVES "M90, #" Ortho-Novum # (ethinyl estradiol / norethindrone-Ortho-Novum) M90 CONTRACEPTIVES "M90, #" Ortho Tri-Cyclen # (ethinyl estradiol / norgestimate-Ortho Tri-Cyclen) M90 CONTRACEPTIVES "M90, #" "Olumiant (baricitinib COVID EUA - November 19, 2020 for members 2 to 17 years of age) MB" COVID - 19 related Treatments and Vaccines MB Olumiant (baricitinib for members ≥ 18 years of age COVID) MB COVID - 19 related Treatments and Vaccines MB Orkambi (lumacaftor / ivacaftor) PD - PA PA CYSTIC FIBROSIS AGENTS PD Onexton (clindamycin / benzoyl peroxide-Onexton) A90 - PA PA DERMATOLOGICAL A90 Opzelura (ruxolitinib cream) - PA PA DERMATOLOGICAL Oxsoralen (methoxsalen topical) A90 DERMATOLOGICAL A90 Oxsoralen-Ultra # (methoxsalen capsules) A90 DERMATOLOGICAL "A90, #" oxymetazoline cream - PA PA DERMATOLOGICAL "Onglyza (saxagliptin) BP, M90" DIABETIC AGENTS "BP, M90" "Oseni (alogliptin / pioglitazone) BP, M90 - PA" PA DIABETIC AGENTS "BP, M90" Ozempic (semaglutide injection-Ozempic) - PA PA DIABETIC AGENTS On-Go (COVID-19 antigen self-test) - PA > 2 tests/28 days; Non-Drug Product PA > 2 tests/28 days DIAGNOSTICS octreotide capsule - PA PA ENDOCRINE/METABOLIC AGENTS octreotide injectable suspension ENDOCRINE/METABOLIC AGENTS octreotide injection ENDOCRINE/METABOLIC AGENTS # octreotide prefilled syringe ENDOCRINE/METABOLIC AGENTS Orfadin # (nitisinone) A90 ENDOCRINE/METABOLIC AGENTS "A90, #" osilodrostat - PA PA ENDOCRINE/METABOLIC AGENTS Olpruva (sodium phenylbutyrate pellets for suspension) - PA PA ENZYMES Orladeyo (berotralstat) - PA PA ENZYMES Oravig (miconazole buccal tablet) - PA PA FUNGICIDES oteseconazole - PA PA FUNGICIDES "oxiconazole cream BP, A90 - PA" PA FUNGICIDES "BP, A90" oxiconazole lotion - PA PA FUNGICIDES "Oxistat (oxiconazole cream) BP, A90 - PA" PA FUNGICIDES "BP, A90" Oxistat (oxiconazole lotion) - PA PA FUNGICIDES "onasemnogene abeparvovec-xioi CO, PD, MB - PA" PA GENE THERAPY "CO, PD, MB" olsalazine GI ANTI-INFLAMMATORY Olux # (clobetasol propionate foam) A90 GLUCOCORTICOIDS "A90, #" Olux-E (clobetasol propionate foam / emollient) A90 - PA PA GLUCOCORTICOIDS A90 Ortikos (budesonide extended-release capsule) - PA PA GLUCOCORTICOIDS Omeclamox-Pak (omeprazole / clarithromycin / amoxicillin) - PA PA H. PYLORI AGENTS omeprazole / amoxicillin / rifabutin - PA PA H. PYLORI AGENTS omeprazole / clarithromycin / amoxicillin - PA PA H. PYLORI AGENTS oprelvekin HEMATINIC AGENT Oxbryta (voxelotor) - PA PA HEMATOLOGIC Omnitrope (somatropin-Omnitrope) - PA PA HORMONE AGENTS Orgovyx (relugolix) - PA PA HORMONE AGENTS Orilissa (elagolix) - PA PA HORMONE AGENTS "Orthovisc (hyaluronan, high molecular weight) MB - PA" PA HYALURONAN MB Olumiant (baricitinib) - PA PA IMMUNOMODULATOR "Orencia (abatacept auto-injection, prefilled syringe) - PA" PA IMMUNOMODULATOR Orencia (abatacept vial) MB - PA PA IMMUNOMODULATOR MB Otezla (apremilast) - PA PA IMMUNOMODULATOR Otrexup (methotrexate subcutaneous injection-Otrexup) - PA PA IMMUNOMODULATOR Osmoprep (sodium phosphate) LAXATIVES omega-3 acid ethyl esters M90 LIPID LOWERING AGENTS "M90, #" olipudase alfa-rpcp MB - PA PA MISCELLANEOUS MB ocrelizumab - PA PA MULTIPLE SCLEROSIS AGENTS Ocrevus (ocrelizumab) - PA PA MULTIPLE SCLEROSIS AGENTS ofatumumab prefilled syringe - PA PA MULTIPLE SCLEROSIS AGENTS orphenadrine / aspirin / caffeine A90 - PA PA MUSCLE RELAXANT A90 orphenadrine A90 - PA < 18 years PA MUSCLE RELAXANT A90 olopatadine / mometasone - PA PA NASAL PREPARATIONS olopatadine nasal spray A90 - PA PA NASAL PREPARATIONS A90 Omnaris (ciclesonide 50 mcg nasal spray) - PA > 1 inhaler/30 days PA > 1 inhaler/30 days NASAL PREPARATIONS oxaprozin A90 NONSTEROIDAL ANTI-INFLAMMATORY "A90, #" Ocuflox # (ofloxacin ophthalmic solution) A90 OPHTHALMIC PREPARATIONS "A90, #" ofloxacin ophthalmic solution A90 OPHTHALMIC PREPARATIONS "A90, #" Omidria (phenylephrine / ketorolac) MB OPHTHALMIC PREPARATIONS MB Opcon-A (naphazoline / pheniramine) A90 OPHTHALMIC PREPARATIONS A90 Oxervate (cenegermin-bkbj) - PA PA OPHTHALMIC PREPARATIONS Ozurdex (dexamethasone intravitreal implant) MB OPHTHALMIC PREPARATIONS MB oliceridine MB - PA PA OPIOID ANALGESICS MB Olinvyk (oliceridine) MB - PA PA OPIOID ANALGESICS MB oxycodone / acetaminophen 300 mg - PA PA OPIOID ANALGESICS oxycodone / acetaminophen - PA > 80 mg/day oxycodone and PA > 4 g/day acetaminophen PA > 80 mg/day oxycodone and PA > 4 g/day acetaminophen OPIOID ANALGESICS oxycodone / acetaminophen-Percocet - PA > 80 mg/day oxycodone and PA > 4 g/day acetaminophen PA > 80 mg/day oxycodone and PA > 4 g/day acetaminophen OPIOID ANALGESICS # oxycodone / aspirin - PA > 80 mg/day oxycodone and PA > 4 g/day aspirin PA > 80 mg/day oxycodone and PA > 4 g/day aspirin OPIOID ANALGESICS oxycodone extended-release capsule - PA PA OPIOID ANALGESICS oxycodone extended-release tablet BP - PA PA OPIOID ANALGESICS BP oxycodone immediate-release - PA > 80 mg/day PA > 80 mg/day OPIOID ANALGESICS # Oxycontin (oxycodone extended-release tablet) BP - PA PA OPIOID ANALGESICS BP "oxymorphone extended-release, oral - PA" PA OPIOID ANALGESICS "oxymorphone immediate-release, oral - PA" PA OPIOID ANALGESICS Oriahnn (elagolix / estradiol / norethindrone) - PA PA OTHER HORMONES ofloxacin otic solution A90 OTIC PREPARATIONS A90 Otovel (ciprofloxacin / fluocinolone) A90 - PA PA OTIC PREPARATIONS A90 omeprazole 10 mg M90 - PA > 1 unit/day PA > 1 unit/day PROTON PUMP INHIBITORS M90 omeprazole 20 mg capsule M90 - PA > 4 units/day PA > 4 units/day PROTON PUMP INHIBITORS M90 omeprazole 40 mg M90 - PA > 2 units/day PA > 2 units/day PROTON PUMP INHIBITORS M90 omeprazole suspension compounding kit - PA PA PROTON PUMP INHIBITORS omeprazole suspension - PA PA PROTON PUMP INHIBITORS Ofev (nintedanib) - PA PA PULMONARY FIBROSIS AGENTS "Onpattro (patisiran) PD, MB - PA" PA SMALL INTERFERING RNA AGENTS "PD, MB" "Oxlumo (lumasiran) PD, MB - PA" PA SMALL INTERFERING RNA AGENTS "PD, MB" ozanimod for multiple sclerosis - PA PA SPHINGOSINE 1-PHOSPHATE RECEPTOR MODULATOR ozanimod for ulcerative colitis - PA PA SPHINGOSINE 1-PHOSPHATE RECEPTOR MODULATOR omaveloxolone - PA PA UNCLASSIFIED DRUG PRODUCTS "omidubicel-onlv CO, MB - PA" PA UNCLASSIFIED DRUG PRODUCTS "CO, MB" "Omisirge (omidubicel-onlv) CO, MB - PA" PA UNCLASSIFIED DRUG PRODUCTS "CO, MB" oxybutynin extended-release tablet A90 URINARY ANTISPASMODICS "A90, #" oxybutynin gel BP URINARY ANTISPASMODICS BP oxybutynin immediate-release 2.5 mg tablet A90 - PA PA URINARY ANTISPASMODICS A90 "oxybutynin immediate-release 5 mg tablet, syrup A90" URINARY ANTISPASMODICS A90 oxybutynin solution A90 - PA PA URINARY ANTISPASMODICS A90 oxybutynin transdermal system URINARY ANTISPASMODICS Oxytrol (oxybutynin transdermal system) URINARY ANTISPASMODICS