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2020 Medicare Prescription Drug Plan Benefit Details for the Mutual of Omaha Rx Value (PDP) - S7126-057
2020 Medicare Prescription Drug Plan Details
Medicare Plan Name:Mutual of Omaha Rx Value (PDP)
   by Mutual of Omaha Rx
State:Nebraska
Plan ID:S7126 - 057 - 0     Click to see other plans
Member Services:1-855-864-6797 TTY users 1-800-716-3231
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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Speak to a licensed sales agent to learn more and enroll.
Call Medicare Solutions at 855-373-9484 / TTY 711
Monday ‐ Friday 8:30am — 10pm EST
MULTIPLAN_GHHJTEXEN_ACCEPTED
Email a copy of the Mutual of Omaha Rx Value (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$24.50 (see Plan Premium Details below)
Annual Deductible:$435 (Tier 1 and 2 excluded from the Deductible.)
$0 Premium if Full 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
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:2,980 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$25.0041%25%
• Number of Drugs per
  Tier:		138690662992498
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 Nebraska:5,205 members
Number of Members enrolled in this plan in your CMS Region:19,538 members     (CMS Region 25)
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 Base
Premium		Part D Supplemental
Premium
$24.50$12.50$12.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$12.00$15.10$18.20$21.40


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