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2022 Medicare Prescription Drug Plan Cost-Sharing Details
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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2022 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Mutual of Omaha Rx Premier (PDP) (S7126-080-0)
Benefit Details        
select insulin pay $35 copay
This plan is available in CMS PDP Region 11
Click on a letter below to view the
Mutual of Omaha Rx Premier (PDP) Formulary
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  0-9 
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) $7.00(E) n/a(E) $0.00(E) $21.00(E) $0.00(E)
Tier 2: Generic: $13.00(E) $20.00(E) n/a(E) $39.00(E) $60.00(E) $39.00(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 $7.00 n/a $0.00 $21.00 $0.00
Tier 2: Generic: $13.00 $20.00 n/a $39.00 $60.00 $39.00
Tier 3: Preferred Brand: 23% 25% n/a 23% 25% 23%
Tier 4: Non-Preferred Drug: 44% 46% 44% 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 $3.95 The greater of 5% or $3.95
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $9.85 The greater of 5% or $9.85
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.
Go to the Mutual of Omaha Rx Premier (PDP) 2022 Formulary Browser by choosing a letter below:
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