2023 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Mutual of Omaha Rx Premier (PDP) (S7126-080-0) Benefit Details ![]() ![]() ![]() all covered insulin pay $35 or less | ||||||
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 |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $1.00(E) | $8.00(E) | n/a(E) | $3.00(E) | $24.00(E) | $2.50(E) |
Tier 2: Generic: | $10.00(E) | $17.00(E) | n/a(E) | $30.00(E) | $51.00(E) | $25.00(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: | $1.00 | $8.00 | n/a | $3.00 | $24.00 | $2.50 |
Tier 2: Generic: | $10.00 | $17.00 | n/a | $30.00 | $51.00 | $25.00 |
Tier 3: Preferred Brand: | $45.00 | $47.00 | n/a | $135.00 | $141.00 | $112.50 |
Tier 4: Non-Preferred Drug: | 45% | 47% | 45% | 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 $4.15 | The greater of 5% or $4.15 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $10.35 | The greater of 5% or $10.35 | ||||
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) 2023 Formulary Browser by choosing a letter below: 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 |