2020 Medicare Prescription Drug Plan Cost-Sharing Details

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2020 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Mutual of Omaha Rx Plus (PDP) (S7126-014-0)
Benefits & Contact Info        
This plan is available in CMS PDP Region 15
which includes: IN KY

Monthly Premium: $52.90
Rx Deductible: $435
Initial Coverage Limit: $4,020 Qualifies for LIS: No


Click on a letter below to view the
Mutual of Omaha Rx Plus (PDP) Formulary
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This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
All Formulary Drug Tiers: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $0.00 $8.00 n/a $0.00 $24.00 $0.00
Tier 2: Generic: $8.00 $14.00 n/a $24.00 $42.00 $24.00
Tier 3: Preferred Brand: $42.00 $47.00 n/a $126.00 $141.00 $126.00
Tier 4: Non-Preferred Drug: 48% 50% 48% n/a n/a n/a
Tier 5: Specialty Tier: 25% 25% 25% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 25% 25% 25% 25% 25% 25%
All Formulary Brand-Name Drugs: 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.60 The greater of 5% or $3.60
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.95 The greater of 5% or $8.95
Go to the Mutual of Omaha Rx Plus (PDP) 2020 Formulary Browser by choosing a letter below:
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