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 Value (PDP) (S7126-053-0)
Benefits & Contact Info        
This plan is available in CMS PDP Region 21
Monthly Premium: $30.90
Rx Deductible: $435
Initial Coverage Limit: $4,020 Qualifies for LIS: No


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Mutual of Omaha Rx Value (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
Tier 1: Preferred Generic: $0.00(E) $10.00(E) n/a(E) $0.00(E) $30.00(E) $0.00(E)
Tier 2: Generic: $2.00(E) $15.00(E) n/a(E) $6.00(E) $45.00(E) $6.00(E)
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Drug: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $0.00 $10.00 n/a $0.00 $30.00 $0.00
Tier 2: Generic: $2.00 $15.00 n/a $6.00 $45.00 $6.00
Tier 3: Preferred Brand: $25.00 $30.00 n/a $75.00 $90.00 $75.00
Tier 4: Non-Preferred Drug: 43% 45% 43% 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
75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap
Tier 1: Preferred Generic: $0.00(A) $10.00(A) n/a $0.00(A) $30.00(A) $0.00(A)
Tier 2: Generic: $2.00(A) $15.00(A) n/a $6.00(A) $45.00(A) $6.00(A)
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
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible.
(A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount.
(P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount.
Go to the Mutual of Omaha Rx Value (PDP) 2020 Formulary Browser by choosing a letter below:
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