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Mutual of Omaha Rx Value (PDP) (S7126-053-0)
Tier 1 (138)
Tier 2 (693)
Tier 3 (661)
Tier 4 (998)
Tier 5 (500)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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2020 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Value (PDP) (S7126-053-0)
Benefit Details           
The Mutual of Omaha Rx Value (PDP) (S7126-053-0)
Formulary Drugs Starting with the Letter I

in CMS PDP Region 21 which includes: LA
Plan Monthly Premium: $30.90 Deductible: $435 Qualifies for LIS: No
Drugs Starting with Letter I

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
IBANDRONATE SODIUM 150 MG TABLET [Boniva]   3 Preferred Brand $25.00$75.00Q:1
/30Days
IBRANCE 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 100 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 125 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 125 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 75 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBU 600 MG TABLET [Toxicology Saliva Collection]   1* Preferred Generic $0.00$0.00None
IBU 800 MG TABLET [Samson-8]   1* Preferred Generic $0.00$0.00None
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [PediaCare Children's Pain Reliever/Fever Reducer IB]   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IBUPROFEN 400 MG TABLET [Motrin]   2* Generic $2.00$6.00None
IBUPROFEN 600 MG TABLET [Toxicology Saliva Collection]   2* Generic $2.00$6.00None
IBUPROFEN 800 MG TABLET   2* Generic $2.00$6.00None
ICATIBANT 30 MG/3 ML SYRINGE [FIRAZYR]   5 Specialty Tier 25%N/AP Q:270
/30Days
ICLUSIG 15 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
ICLUSIG 45 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IDHIFA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IDHIFA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMATINIB MESYLATE 100 MG TABLET [Gleevec]   5 Specialty Tier 25%N/AP Q:180
/30Days
IMATINIB MESYLATE 400 MG TABLET [Gleevec]   5 Specialty Tier 25%N/AP Q:60
/30Days
IMBRUVICA 140 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IMBRUVICA 140 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 280 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 420 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 560 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 70 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
IMIPRAMINE HCL 10MG TABLET (100 CT)   4 Non-Preferred Drug 43%N/AP
IMIPRAMINE HCL 25MG TABLET (100 CT)   4 Non-Preferred Drug 43%N/AP
IMIPRAMINE HCL 50 MG TABLET   4 Non-Preferred Drug 43%N/AP
IMIQUIMOD 5% CREAM PACKET   3 Preferred Brand $25.00$75.00None
IMOVAX RABIES VACCINE   4 Non-Preferred Drug 43%N/ANone
INCASSIA 0.35 MG TABLET [Sharobel 28-Day]   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier 25%N/AP
INCRUSE ELLIPTA 62.5 MCG INH   3 Preferred Brand $25.00$75.00Q:30
/30Days
INDAPAMIDE 1.25 MG TABLET [Lozol]   2* Generic $2.00$6.00None
INDAPAMIDE 2.5 MG TABLET [Lozol]   2* Generic $2.00$6.00None
INFANRIX DTAP VIAL   3 Preferred Brand $25.00$75.00None
INLYTA 1 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
INLYTA 5 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
INREBIC 100 MG CAPSULE   4 Non-Preferred Drug 43%N/AP Q:120
/30Days
INTELENCE 100MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
INTELENCE 200 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
INTELENCE 25 MG TABLET   4 Non-Preferred Drug 43%N/AQ:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INTRALIPID 20% IV FAT EMULSION   4 Non-Preferred Drug 43%N/AP
INTRALIPID 30% IV FAT EMULSION   3 Preferred Brand $25.00$75.00P
INTRON A 10 MILLION UNITS VIAL   5 Specialty Tier 25%N/AP
INTRON A 18 MILLION UNITS VIAL   5 Specialty Tier 25%N/AP
INTRON A 25 MILLION UNIT/2.5ML VIAL   5 Specialty Tier 25%N/AP
INTRON A 50 MILLION UNITS VIAL   5 Specialty Tier 25%N/AP
INTRON A 6MMU/ML VIAL   5 Specialty Tier 25%N/AP
Invega Sustenna 117 mg/0.75mL Prefilled Syringe   4 Non-Preferred Drug 43%N/AQ:1
/28Days
Invega Sustenna 156 mg/mL Prefilled Syringe   4 Non-Preferred Drug 43%N/AQ:1
/28Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe   4 Non-Preferred Drug 43%N/AQ:2
/28Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe   4 Non-Preferred Drug 43%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Invega Sustenna 78 mg/0.5mL Prefilled Syringe   4 Non-Preferred Drug 43%N/AQ:1
/28Days
INVEGA TRINZA 273 MG/0.875 ML   4 Non-Preferred Drug 43%N/AQ:1
/28Days
INVEGA TRINZA 410 MG/1.315 ML   4 Non-Preferred Drug 43%N/AQ:1
/28Days
INVEGA TRINZA 546 MG/1.75 ML   4 Non-Preferred Drug 43%N/AQ:2
/28Days
INVEGA TRINZA 819 MG/2.625 ML   4 Non-Preferred Drug 43%N/AQ:3
/28Days
INVELTYS 1% EYE DROP EYE DROPPER   4 Non-Preferred Drug 43%N/ANone
INVIRASE 500MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
INVOKAMET 150-1,000 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKAMET 150-500 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKAMET 50-1,000 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKAMET 50-500 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INVOKAMET XR 150-1,000 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKAMET XR 150-500 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKAMET XR 50-1,000 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKAMET XR 50-500 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
INVOKANA 100 MG TABLET   3 Preferred Brand $25.00$75.00Q:30
/30Days
INVOKANA 300 MG TABLET   3 Preferred Brand $25.00$75.00Q:30
/30Days
IPOL VIAL 40;8;32; UNT   3 Preferred Brand $25.00$75.00None
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML   2* Generic $2.00$6.00P
IPRATROPIUM 0.06% SPRAY   2* Generic $2.00$6.00Q:30
/30Days
IPRATROPIUM BR 0.02% SOLN   2* Generic $2.00$6.00P
IPRATROPIUM BROMIDE NASAL SPRAY   2* Generic $2.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IRBESARTAN 150 MG TABLET [Avapro]   1* Preferred Generic $0.00$0.00Q:30
/30Days
IRBESARTAN 300 MG TABLET [Avapro]   1* Preferred Generic $0.00$0.00Q:30
/30Days
IRBESARTAN 75 MG TABLET [Avapro]   1* Preferred Generic $0.00$0.00Q:30
/30Days
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide]   2* Generic $2.00$6.00Q:30
/30Days
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide]   2* Generic $2.00$6.00Q:30
/30Days
IRESSA 250 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ISENTRESS 100 MG POWDER PACKET   5 Specialty Tier 25%N/AQ:60
/30Days
ISENTRESS 100 MG TABLET CHEW   5 Specialty Tier 25%N/AQ:180
/30Days
ISENTRESS 25 MG TABLET CHEW   3 Preferred Brand $25.00$75.00Q:180
/30Days
ISENTRESS 400MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
ISENTRESS HD 600 MG TABLET   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISIBLOOM 28 DAY TABLET [Solia]   4 Non-Preferred Drug 43%N/ANone
ISONIAZID 100 MG TABLET   2* Generic $2.00$6.00None
ISONIAZID 300 MG TABLET   2* Generic $2.00$6.00None
ISONIAZID 50MG/5ML SYRUP   4 Non-Preferred Drug 43%N/ANone
ISORDIL 40 MG TABLET   4 Non-Preferred Drug 43%N/ANone
ISOSORBIDE DINITRATE 20 MG TABLET [Wesorbide]   4 Non-Preferred Drug 43%N/ANone
ISOSORBIDE DINITRATE 40 MG TABLET [Sorbitrate]   4 Non-Preferred Drug 43%N/ANone
ISOSORBIDE DN 10 MG TABLET   4 Non-Preferred Drug 43%N/ANone
ISOSORBIDE DN 30 MG TABLET   3 Preferred Brand $25.00$75.00None
ISOSORBIDE DN 5 MG TABLET   4 Non-Preferred Drug 43%N/ANone
ISOSORBIDE MN ER 30 MG TABLET   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOSORBIDE MN ER 60 MG TABLET   2* Generic $2.00$6.00None
ISOSORBIDE MONONIT 10 MG TABLET [Monoket]   2* Generic $2.00$6.00None
ISOSORBIDE MONONIT 20 MG TABLET [Monoket]   2* Generic $2.00$6.00None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   2* Generic $2.00$6.00None
ISOTON GENTAMICIN 80MG/100ML   2* Generic $2.00$6.00None
ISOTONIC GENTAMICIN 100 MG/100 ML   4 Non-Preferred Drug 43%N/ANone
ISOTONIC GENTAMICIN 80 MG/50 ML   2* Generic $2.00$6.00None
ISOTRETINOIN 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 43%N/ANone
ISOTRETINOIN 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 43%N/ANone
ISOTRETINOIN 30 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 43%N/ANone
ISOTRETINOIN 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 43%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ITRACONAZOLE 10 MG/ML SOLUTION [Sporanox]   3 Preferred Brand $25.00$75.00None
ITRACONAZOLE 100 MG CAPSULE [Sporanox]   3 Preferred Brand $25.00$75.00Q:120
/30Days
IVERMECTIN 3 MG TABLET [Stromectol, Sklice]   3 Preferred Brand $25.00$75.00None
IXIARO 6 UNIT(6 MCG)/0.5ML SYRINGE   4 Non-Preferred Drug 43%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Mutual of Omaha Rx Value (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.