2019 Medicare Prescription Drug Price Information |
Mutual of Omaha Rx Value (PDP) (S7126-044-0)
Benefit Details
|
Monthly Premium: $28.80 Rx Deductible: $415 ICL: $3,820 Qualifies for LIS: No
Click on a letter below to view the Mutual of Omaha Rx Value (PDP) Formulary
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
0-9
|
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies |
UPTRAVI 600 MCG TABLET |
Plan’s average negotiated retail drug price in CMS PDP Region 12, includes: AL TN | $17,595.40* 30-Day Supply $53,315.70* 90-Day Supply
|
Formulary (Drug List) drug tier: | Tier #5: Specialty Tier
|
Does this plan offer any Gap coverage? | No Gap Coverage |
Does this drug have Gap coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. |
Drug Usage Management Restrictions: | Prior Authorization
|
Formulary (Drug List) Tier Cost-Sharing Details |
|
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Initial $415 Deductible Cost Sharing: |
| 100% | 100% | 100% |
n/a | n/a | n/a |
Initial Coverage Phase Cost-Sharing: |
| 25% | 25% | 25% |
n/a | n/a | n/a |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 63%): |
| 37% | 37% | 37% |
n/a | n/a | n/a |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%): |
| 25% | 25% | 25% |
n/a | n/a | n/a |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: |
| The greater of 5% or $3.40 |
The greater of 5% or $3.40 |
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): |
| The greater of 5% or $8.50 |
The greater of 5% or $8.50 |
Your Estimated Cost for Purchases During Each Coverage Phase |
|
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Your Estimated Cost in Deductible Phase: |
| $2,762.13 | $2,762.13 | $2,762.13 |
n/a | n/a | n/a |
Your Estimated Cost Initial Coverage Phase: |
| $2,516.40 | $2,516.40 | $2,516.40 |
n/a | n/a | n/a |
Your Estimated Cost in Gap if Drug is Generic (63% discount): |
| $5,290.58 | $5,290.58 | $5,290.58 |
$7,076.60 | n/a | n/a |
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): |
| $1,953.45 | $1,953.45 | $1,953.45 |
$3,673.04 | n/a | n/a |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): |
| $879.77 | $879.77 | $879.77 |
n/a | n/a | n/a |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): |
| $879.77 | $879.77 | $879.77 |
n/a | n/a | n/a |
Tier Cost-Sharing Details and Your Costs with Explanations |
|
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
--- If you purchase during the Initial Deductible Phase --- |
Initial $415 Deductible Cost Sharing: |
| 100% | 100% | 100% |
n/a | n/a | n/a |
Your Estimated Cost in Deductible Phase: |
| $2,762.13 | $2,762.13 | $2,762.13 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
|
For a purchase of this drug made during the initial deductible phase,
you cross over into other phases of your plan’s coverage (straddle claim).
So you pay 100% of the drug cost up to your deductible of $415
and the remaining amount ($17,595.40-$415) (price - deductible) falls
into your initial coverage phase (ICP).
For the ICP portion of your coverage, your cost-sharing would be an additional $851.25
or $3,405.00 x 25%
(overage up to your remaining coverage limit
($3,405.00) * cost-sharing). Since the amount of the retail drug price falling into the ICP
$17,180.40 is greater than the remaining
initial coverage limit $3405 ($3,820 - $415),
$13,775.40 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase,
you would pay an additional
$1,008.88
or ($4,035.53 x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP assuming this is a brand-name drug). Since the portion of the costs that fell into the coverage gap
$13,775.40 x 95% exceeds the amount
of TrOOP left ($3,833.75),
$9,739.87 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase, you would pay an additional $486.99 or (5% of $9,739.87) since it is greater than the minimum catastrophic cost-share of $8.50. |
--- If you purchase during the Initial Coverage Phase --- |
Initial Coverage Phase Cost-Sharing: |
| 25% | 25% | 25% |
n/a | n/a | n/a |
Your Estimated Cost Initial Coverage Phase: |
| $2,516.40 | $2,516.40 | $2,516.40 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
| The cost-sharing for purchases made during the initial coverage phase (ICP) would be $955.00 or ($3,820.00 x 25%). But since the retail drug price ($17,595.40) is greater than initial coverage limit ($3,820), the difference of $13,775.40 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase,
you would pay an additional
$1,090.79
or ($4,363.16 x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP). The portion of the costs that fell into the coverage gap $4,363.16 exceeds the amount of TrOOP left ($4,145.00) so you only pay in the gap on the amount within the TrOOP. The excess over TrOOP, $9,412.24 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase,
you would pay an additional $470.61 or (5% of $9,412.24) since it is greater than the minimum catastrophic cost-share of $8.50. So, your total cost for this one purchase is $2,516.40 or $955.00 (ICP) + $1,090.79 (Gap) + $470.61 (Cat.Cov.). |
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- |
Your Estimated Cost in Gap if Drug is Generic (63% discount): |
| $5,290.58 | $5,290.58 | $5,290.58 |
$7,076.60 | n/a | n/a |
|
Since this drug’s negotiated retail price ($17,595.40) is greater than
the TrOOP limit ($5,100), in the donut hole phase, you would pay
$5,100.00 ($13,783.78 x 37%)
plus $190.58 in the catastrophic phase, (which is 5% of the remaining $3,811.62) because $190.58 is greater than the minimum catastrophic cost-share of $3.40. Although it rarely happens that you would be responsible for the entire $5,100 for a purchase in the coverage gap, it can occur, for example on an expensive generic drug with a $0 copay in the initial coverage phase. |
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): |
| $1,953.45 | $1,953.45 | $1,953.45 |
$3,673.04 | n/a | n/a |
|
Since 95% this drug’s negotiated
retail price ($17,595.40) is greater than
the TrOOP limit ($5,100), in the donut hole phase, you would pay
$1,342.11 (($5,100 / 95%) x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP)
plus $611.35 in the catastrophic phase, (which is 5% of the remaining
$12,226.98)
because $611.35 is greater than the minimum catastrophic cost-share of $8.50.
Although it rarely happens that you would be responsible for the entire
$5,100 for a purchase in the coverage gap, it can occur, for example
on an expensive generic drug with a $0 copay in the initial coverage phase. |
--- If you purchase during the Catastrophic Coverage Phase --- |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: |
| The greater of 5% or $3.40 |
The greater of 5% or $3.40 |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): |
| $879.77 | $879.77 | $879.77 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
| In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $3.40. Calculating 5% of $17,595.40 = $879.77. Since $879.77 is more than $3.40, you would pay $879.77 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug. |
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): |
| The greater of 5% or $8.50 |
The greater of 5% or $8.50 |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): |
| $879.77 | $879.77 | $879.77 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
| In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $8.50. Calculating 5% of $17,595.40 = $879.77. Since $879.77 is more than $8.50, you would pay $879.77 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. |
Mutual of Omaha Rx Value (PDP) Average Negotiated Retail Drug Price History |
| 30-Day Supply | 90 Day Supply |
September, 2019: | $17,595.40 | $53,315.70 |
June, 2019: | $17,646.40 | $53,412.90 |
March, 2019: | $17,729.80 | $53,931.20 |
January, 2019: | $16,744.60 | $51,486.40 |
September, 2018: | n/a | n/a |
June, 2018: | n/a | n/a |
March, 2018: | n/a | n/a |
January, 2018: | n/a | n/a |
September, 2017: | n/a | n/a |
June, 2017: | n/a | n/a |
March, 2017: | n/a | n/a |
January, 2017: | n/a | n/a |
September, 2016: | | |
June, 2016: | | |
April, 2016: | | |
January, 2016: | | |
September, 2015: | | |
June, 2015: | | |
April, 2015: | | |
January, 2015: | | |
September, 2014: | | |
June, 2014: | | |
March, 2014: | | |
January, 2014: | | |
October, 2013: | | |
January, 2013: | | -- |
April, 2012: | | -- |
September, 2010: | | -- |
Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several
variables: the medication, the quantity of your prescription, the specific Medicare Part D
plan, and the pharmacies in the plan’s service area. In this case, the average of
the UPTRAVI 600 MCG TABLET prices that the Mutual of Omaha Rx Value (PDP) has negotiated with each of the retail pharmacies
in the plan’s service area (CMS PDP Region 12, includes: AL TN).
In other words, when you use the Mutual of Omaha Rx Value (PDP) to purchase UPTRAVI 600 MCG TABLET, you may pay slightly more
or slightly less than the figures shown in the table above depending on the pharmacy where
you fill your prescription and the quantity of your prescription.
**The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
|
Return to the Mutual of Omaha Rx Value (PDP) 2019 Formulary Browser by choosing a letter below:
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
0-9
|