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2020 Medicare Prescription Drug Plan Benefit Details for the Mutual of Omaha Rx Value (PDP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2020 Medicare Prescription Drug Plan Details
Medicare Plan Name:Mutual of Omaha Rx Value (PDP)
   by Mutual of Omaha Rx
State:Florida
Plan ID:S7126 - 043 - 0     Click to see other plans
Member Services:1-855-864-6797 TTY users 1-800-716-3231
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the Mutual of Omaha Rx Value (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$25.80 (see Plan Premium Details below)
Annual Deductible:$435 (Tier 1 and 2 excluded from the Deductible.)
$0 Premium if LIS Benefits?No, this plan does NOT qualify for the $0 Premium. (See premiums for partial LIS subsidy below.)
Annual Initial Coverage Limit (ICL):$4,020
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:2,990 drugsBrowse the Mutual of Omaha Rx Value (PDP) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$2.00$25.0048%25%
• Number of Drugs per
  Tier:		138693661998500
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 610014   PCN: MEDDPRIME   See BIN/PCNs for all plans
Plan Type (Reach):Regional Plan
Number of Members enrolled in this plan in Florida:8,747 members     (CMS Region 11)
Number of Members enrolled in this plan nationally:179,132 members
Plan’s Summary Star Rating: New plan - No summary rating as of yet.
• Customer Service Rating: New plan - not yet rated.
• Member Experience Rating: New plan - not yet rated.
• Drug Cost Accuracy Rating: Does not apply.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part D Basic
Premium		Part D Supplemental
Premium
$25.80$3.70$22.10
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$22.10$23.00$23.90$24.90




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