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2021 Medicare Prescription Drug Plan Benefit Details for the Mutual of Omaha Rx Premier (PDP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2021 Medicare Prescription Drug Plan Details
Medicare Plan Name:Mutual of Omaha Rx Premier (PDP)
   by Mutual of Omaha Rx
State:Montana
Plan ID:S7126 - 094 - 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 Premier (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$23.00 (see Plan Premium Details below)
Annual Deductible:$445 (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):$4,130
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:2,993 drugsBrowse the Mutual of Omaha Rx Premier (PDP) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
This plan offers select insulin at a $25 copay. Learn more.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$2.0023%46%25%
• Number of Drugs per
  Tier:		138681722937515
Plan Offers Mail Order?Yes
Plan Type (Reach):Regional Plan
Number of Members enrolled in this plan in Montana:1,014 members
Number of Members enrolled in this plan in your CMS Region:17,366 members     (CMS Region 25)
Number of Members enrolled in this plan nationally:137,379 members
Plan’s Summary Star Rating: 2.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: New plan - not yet rated.
• Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part D Basic
Premium		Part D Supplemental
Premium
$23.00$-9.40$32.40
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$23.00$23.00$23.00$23.00




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