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Mutual of Omaha Rx Value (PDP) (S7126-038-0)
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2019 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Value (PDP) (S7126-038-0)
Benefit Details           
The Mutual of Omaha Rx Value (PDP) (S7126-038-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 6 which includes: PA WV
Plan Monthly Premium: $26.40 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter D

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
D-AMPHETAMINE ER 10 MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
D-AMPHETAMINE ER 15 MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
D-AMPHETAMINE ER 5 MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN   2* Generic $4.00$8.00None
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN   2* Generic $4.00$8.00None
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 25%N/AP Q:60
/30Days
DALIRESP 250 MCG TABLET   4 Non-Preferred Drug 36%N/AP
DALIRESP 500 MCG TABLET   4 Non-Preferred Drug 36%N/AP Q:30
/30Days
DANAZOL 100 MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 36%N/ANone
DANTROLENE SODIUM 100MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
DANTROLENE SODIUM 25MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
DANTROLENE SODIUM 50MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
DAPSONE 25 MG TABLET   3 Preferred Brand 15%18%None
DAPSONE 5% GEL   3 Preferred Brand 15%18%None
DAPSONE TABLETS 100MG 30 BLPK   3 Preferred Brand 15%18%None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand 15%18%None
DAPTOMYCIN 350 MG VIAL [Cubicin RF]   3 Preferred Brand 15%18%None
DAPTOMYCIN 500 MG VIAL [Cubicin]   5 Specialty Tier 25%N/ANone
DARAPRIM 25 MG TABLET   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DARIFENACIN ER 15 MG TABLET [Enablex]   4 Non-Preferred Drug 36%N/ANone
DARIFENACIN ER 7.5 MG TABLET [Enablex]   4 Non-Preferred Drug 36%N/ANone
DAURISMO 100 MG TABLET   4 Non-Preferred Drug 36%N/AP
DAURISMO 25 MG TABLET   4 Non-Preferred Drug 36%N/AP
DDAVP 10 MCG/0.1 ML SOLUTION   3 Preferred Brand 15%18%None
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DELSTRIGO 100-300-300 MG TABLET   4 Non-Preferred Drug 36%N/ANone
Delyla-28 tablet   4 Non-Preferred Drug 36%N/ANone
DELZICOL DR 400 MG CAPSULE   4 Non-Preferred Drug 36%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEMECLOCYCLINE 150 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DEMECLOCYCLINE 300 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DEMSER CAPSULES 250MG (100 CT)   4 Non-Preferred Drug 36%N/AP
DENAVIR 1% CREAM (g)   3 Preferred Brand 15%18%None
DEPEN 250MG TITRATAB   5 Specialty Tier 25%N/ANone
DESCOVY 200-25 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
DESIPRAMINE 10 MG TABLET [Norpramin]   4 Non-Preferred Drug 36%N/ANone
DESIPRAMINE 100 MG TABLET [Norpramin]   4 Non-Preferred Drug 36%N/ANone
DESIPRAMINE 150 MG TABLET [Norpramin]   4 Non-Preferred Drug 36%N/ANone
DESIPRAMINE 25 MG TABLET [Norpramin]   4 Non-Preferred Drug 36%N/ANone
DESIPRAMINE 50 MG TABLET [Norpramin]   4 Non-Preferred Drug 36%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE 75 MG TABLET [Norpramin]   4 Non-Preferred Drug 36%N/ANone
DESMOPRESSIN ACETATE 0.1 MG TB   3 Preferred Brand 15%18%None
DESMOPRESSIN ACETATE 0.2 MG TB   3 Preferred Brand 15%18%None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   3 Preferred Brand 15%18%None
Desonide 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 36%N/ANone
DESONIDE 0.05% CREAM   4 Non-Preferred Drug 36%N/ANone
DESONIDE 0.05% LOTION   4 Non-Preferred Drug 36%N/ANone
Desoximetasone 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 36%N/ANone
DESOXIMETASONE 0.25% CREAM   4 Non-Preferred Drug 36%N/ANone
DESOXIMETASONE 0.25% OINTMENT   4 Non-Preferred Drug 36%N/ANone
DESOXIMETASONE 0.25% SPRAY [Topicort]   4 Non-Preferred Drug 36%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 36%N/ANone
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 36%N/ANone
Desvenlafaxine Succinate ER 100 mg [Pristiq]   3 Preferred Brand 15%18%Q:30
/30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   3 Preferred Brand 15%18%Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   3 Preferred Brand 15%18%Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   2* Generic $4.00$8.00None
DEXAMETHASONE 0.5MG TABLET   2* Generic $4.00$8.00None
DEXAMETHASONE 0.5MG/0.5ML DROP   2* Generic $4.00$8.00None
DEXAMETHASONE 0.5MG/5ML ELX   2* Generic $4.00$8.00None
DEXAMETHASONE 0.75MG TABLET   2* Generic $4.00$8.00None
DEXAMETHASONE 1.5MG TABLET   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 10 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2* Generic $4.00$8.00None
DEXAMETHASONE 13 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2* Generic $4.00$8.00None
DEXAMETHASONE 1MG TABLET   2* Generic $4.00$8.00None
DEXAMETHASONE 2MG TABLET   2* Generic $4.00$8.00None
DEXAMETHASONE 4MG TABLET   2* Generic $4.00$8.00None
DEXAMETHASONE 6 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2* Generic $4.00$8.00None
DEXAMETHASONE 6MG TABLET   2* Generic $4.00$8.00None
DEXCHLORPHENIRAMINE 2 MG/5 ML SYRUP [RyClora]   3 Preferred Brand 15%18%None
DEXILANT CAPSULES DELAYED RELEASE 30 MG   4 Non-Preferred Drug 36%N/AQ:30
/30Days
DEXILANT DR 60 MG CAPSULE   4 Non-Preferred Drug 36%N/AQ:30
/30Days
DEXTROAMP-AMPHET ER 10 MG CAP   3 Preferred Brand 15%18%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMP-AMPHET ER 15 MG CAP   3 Preferred Brand 15%18%Q:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAP   3 Preferred Brand 15%18%Q:60
/30Days
DEXTROAMP-AMPHET ER 25 MG CAP   3 Preferred Brand 15%18%Q:60
/30Days
DEXTROAMP-AMPHET ER 30 MG CAP   3 Preferred Brand 15%18%Q:60
/30Days
DEXTROAMP-AMPHET ER 5 MG CAP   3 Preferred Brand 15%18%Q:60
/30Days
DEXTROAMPHETAMINE 10 MG TAB   2* Generic $4.00$8.00None
DEXTROAMPHETAMINE 5 MG TAB   2* Generic $4.00$8.00None
DEXTROSE 10%-1/4NS IV TUBEX   3 Preferred Brand 15%18%None
Dextrose 10%-water iv solution   3 Preferred Brand 15%18%None
DEXTROSE 2.5%-1/2NS IV SOLUTION   3 Preferred Brand 15%18%None
DEXTROSE 5%-0.45% NACL IV SOLN   3 Preferred Brand 15%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE 5%-0.9% NACL IV SOLN   3 Preferred Brand 15%18%None
DEXTROSE 5%-1/4NS IV SOLUTION   3 Preferred Brand 15%18%None
DEXTROSE 5%-WATER IV SOLN   3 Preferred Brand 15%18%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   3 Preferred Brand 15%18%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   3 Preferred Brand 15%18%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   3 Preferred Brand 15%18%None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 36%N/ANone
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 36%N/ANone
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Drug 36%N/ANone
DIAZEPAM 10 MG TABLET [Valium]   2* Generic $4.00$8.00P Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   2* Generic $4.00$8.00P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIAZEPAM 5 MG TABLET [Valium]   2* Generic $4.00$8.00P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   2* Generic $4.00$8.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2* Generic $4.00$8.00P Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2* Generic $4.00$8.00None
Diclofenac sodium 1.5% soln   2* Generic $4.00$8.00Q:300
/28Days
Diclofenac Sodium 1% gel   2* Generic $4.00$8.00Q:1000
/28Days
DICLOXACILLIN 250MG CAPSULE   2* Generic $4.00$8.00None
DICLOXACILLIN SODIUM 500MG CAP   2* Generic $4.00$8.00None
DICYCLOMINE 10 MG CAPSULE   2* Generic $4.00$8.00None
DICYCLOMINE 20 MG TABLET   2* Generic $4.00$8.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   3 Preferred Brand 15%18%Q:30
/30Days
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   3 Preferred Brand 15%18%Q:30
/30Days
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   3 Preferred Brand 15%18%Q:30
/30Days
DIFLORASONE 0.05% CREAM   4 Non-Preferred Drug 36%N/ANone
DIFLORASONE 0.05% OINTMENT   4 Non-Preferred Drug 36%N/ANone
DIFLUNISAL 500 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DIGITEK 125 MCG TABLET   3 Preferred Brand 15%18%Q:30
/30Days
DIGITEK 250 MCG TABLET   3 Preferred Brand 15%18%None
DIGOX 125 MCG TABLET   2* Generic $4.00$8.00Q:30
/30Days
DIGOX 250 MCG TABLET   2* Generic $4.00$8.00None
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOXIN 125 MCG TABLET [Lanoxin]   2* Generic $4.00$8.00Q:30
/30Days
DIGOXIN 250 MCG TABLET [Lanoxin]   2* Generic $4.00$8.00None
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 36%N/ANone
DILT XR 120 MG CAPSULE   2* Generic $4.00$8.00None
DILT XR 180 MG CAPSULE   2* Generic $4.00$8.00None
DILT XR 240 MG CAPSULE   2* Generic $4.00$8.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2* Generic $4.00$8.00None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand 15%18%None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   3 Preferred Brand 15%18%None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   3 Preferred Brand 15%18%None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   3 Preferred Brand 15%18%None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   2* Generic $4.00$8.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   2* Generic $4.00$8.00None
DILTIAZEM 24HR ER 360 MG CAP [Tiazac]   3 Preferred Brand 15%18%None
DILTIAZEM 24HR ER 420 MG CAP [Tiazac]   3 Preferred Brand 15%18%None
DILTIAZEM 30 MG TABLET [Cardizem]   2* Generic $4.00$8.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2* Generic $4.00$8.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2* Generic $4.00$8.00None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand 15%18%None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand 15%18%None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand 15%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand 15%18%None
DIPYRIDAMOLE 25 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DIPYRIDAMOLE 50 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DIPYRIDAMOLE 75 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DISULFIRAM 250 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DISULFIRAM 500 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DIVALPROEX DR 125 MG CAP SPRNK   4 Non-Preferred Drug 36%N/ANone
DIVALPROEX SOD DR 125 MG TAB   2* Generic $4.00$8.00None
DIVALPROEX SOD DR 250 MG TAB   2* Generic $4.00$8.00None
DIVALPROEX SOD DR 500 MG TAB   2* Generic $4.00$8.00None
DIVALPROEX SOD ER 500 MG TAB   4 Non-Preferred Drug 36%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   4 Non-Preferred Drug 36%N/ANone
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   3 Preferred Brand 15%18%None
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   3 Preferred Brand 15%18%None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   3 Preferred Brand 15%18%None
DONEPEZIL HCL 10 MG TABLET   2* Generic $4.00$8.00Q:69
/30Days
DONEPEZIL HCL 5 MG TABLET   2* Generic $4.00$8.00Q:30
/30Days
DONEPEZIL HCL ODT 10 MG TABLET   2* Generic $4.00$8.00Q:69
/30Days
DONEPEZIL HCL ODT 5 MG TABLET   2* Generic $4.00$8.00Q:30
/30Days
DOPTELET 20 MG TABLET   5 Specialty Tier 25%N/AP
DOPTELET 20 MG TABLET   5 Specialty Tier 25%N/AP
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   4 Non-Preferred Drug 36%N/ANone
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF]   3 Preferred Brand 15%18%None
DOVATO 50-300 MG TABLET   5 Specialty Tier 25%N/ANone
DOXAZOSIN MESYLATE 1 MG TAB   2* Generic $4.00$8.00Q:30
/30Days
DOXAZOSIN MESYLATE 2 MG TAB   2* Generic $4.00$8.00Q:30
/30Days
DOXAZOSIN MESYLATE 4 MG TAB   2* Generic $4.00$8.00Q:30
/30Days
DOXAZOSIN MESYLATE 8 MG TAB   2* Generic $4.00$8.00Q:60
/30Days
DOXEPIN 10 MG/ML ORAL CONC   4 Non-Preferred Drug 36%N/AP
DOXEPIN 10MG CAPSULE   4 Non-Preferred Drug 36%N/AP
DOXEPIN 50 MG CAPSULE   4 Non-Preferred Drug 36%N/AP
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 36%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN HCL 25MG CAPSULE (100 CT)   4 Non-Preferred Drug 36%N/AP
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 36%N/AP
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   4 Non-Preferred Drug 36%N/AP
DOXY 100 VIAL   4 Non-Preferred Drug 36%N/ANone
doxycycline 25 mg/5 ml susp   4 Non-Preferred Drug 36%N/ANone
Doxycycline 75mg/1   4 Non-Preferred Drug 36%N/ANone
DOXYCYCLINE HYCLATE 100 MG CAP   2* Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 100 MG TAB   2* Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 150 MG TAB   2* Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   2* Generic $4.00$8.00None
DOXYCYCLINE HYCLATE 50 MG CAP   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 75 MG TAB   2* Generic $4.00$8.00None
DOXYCYCLINE MONO 100 MG CAP   4 Non-Preferred Drug 36%N/ANone
DOXYCYCLINE MONO 100 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DOXYCYCLINE MONO 150 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DOXYCYCLINE MONO 50 MG CAP   4 Non-Preferred Drug 36%N/ANone
DOXYCYCLINE MONO 50 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DOXYCYCLINE MONO 75 MG TABLET   4 Non-Preferred Drug 36%N/ANone
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 36%N/AP Q:60
/30Days
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 36%N/AP Q:60
/30Days
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 36%N/AP Q:60
/30Days
DROSP-EE-LEVOMEF 3-0.02-0.451 TABLET [Beyaz]   4 Non-Preferred Drug 36%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DROSPIRENONE-EE 3-0.02 MG TAB   4 Non-Preferred Drug 36%N/ANone
DROSPIRENONE-EE 3-0.03 MG TAB   4 Non-Preferred Drug 36%N/ANone
DROXIA 200MG CAPSULE   3 Preferred Brand 15%18%None
DROXIA 300MG CAPSULE   3 Preferred Brand 15%18%None
DROXIA 400MG CAPSULE   3 Preferred Brand 15%18%None
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta]   3 Preferred Brand 15%18%Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta]   3 Preferred Brand 15%18%Q:60
/30Days
DULOXETINE HCL DR 40 MG CAPSULE DR [Irenka]   3 Preferred Brand 15%18%Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta]   3 Preferred Brand 15%18%Q:60
/30Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 25%N/AP
DUPIXENT 300 MG/2 ML SAFE SYRG   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
duramorph 0.5 mg/ml ampule   4 Non-Preferred Drug 36%N/AQ:4000
/30Days
duramorph 1 mg/ml ampule   4 Non-Preferred Drug 36%N/AQ:2000
/30Days
DUTASTERIDE 0.5 MG CAPSULE   4 Non-Preferred Drug 36%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Mutual of Omaha Rx Value (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $415 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2019 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.