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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 V

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
VALACYCLOVIR HCL 1 GRAM TABLET [Valtrex]   4 Non-Preferred Drug 43%N/AQ:120
/30Days
VALACYCLOVIR HCL 500 MG TABLET [Valtrex]   4 Non-Preferred Drug 43%N/AQ:60
/30Days
VALCHLOR 0.016% GEL   5 Specialty Tier 25%N/AP
VALGANCICLOVIR 450 MG TABLET [Valcyte]   5 Specialty Tier 25%N/ANone
VALGANCICLOVIR HCL 50 MG/ML [Valcyte]   5 Specialty Tier 25%N/ANone
VALPROIC ACID 250 MG CAPSULE [Depakene]   2* Generic $2.00$6.00None
VALPROIC ACID 250 MG/5 ML SOLN Solution [Depakene]   2* Generic $2.00$6.00None
VALSARTAN 160 MG TABLET [Diovan]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN 320 MG TABLET [Diovan]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN 40 MG TABLET [Diovan]   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
VALSARTAN 80 MG TABLET [Diovan]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]   2* Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]   2* Generic $2.00$6.00Q:30
/30Days
VALTOCO 10 MG NASAL SPRAY   4 Non-Preferred Drug 43%N/AP Q:10
/30Days
VALTOCO 15 MG NASAL SPRAY   4 Non-Preferred Drug 43%N/AP Q:10
/30Days
VALTOCO 20 MG NASAL SPRAY   4 Non-Preferred Drug 43%N/AP Q:10
/30Days
VALTOCO 5 MG NASAL SPRAY   4 Non-Preferred Drug 43%N/AP Q:10
/30Days
VANCOMYCIN 1 GM VIAL [Vancocin]   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VANCOMYCIN 500 MG VIAL   4 Non-Preferred Drug 43%N/ANone
VANCOMYCIN HCL 125 MG CAPSULE [Vancocin]   3 Preferred Brand $25.00$75.00Q:120
/30Days
VANCOMYCIN HCL 250 MG CAPSULE [Vancocin]   5 Specialty Tier 25%N/AQ:240
/30Days
VANCOMYCIN HCL 250 MG VIAL   4 Non-Preferred Drug 43%N/ANone
VANCOMYCIN HCL 750 MG VIAL   4 Non-Preferred Drug 43%N/ANone
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   4 Non-Preferred Drug 43%N/ANone
VANDAZOLE 0.75% GEL WITH APPLICATOR   3 Preferred Brand $25.00$75.00None
VAQTA 25 UNITS/0.5 ML SYRINGE   3 Preferred Brand $25.00$75.00None
VAQTA 50 UNITS/ML SYRINGE   3 Preferred Brand $25.00$75.00None
VAQTA 50 UNITS/ML VIAL   3 Preferred Brand $25.00$75.00None
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VARIVAX VACCINE W/DILUENT   3 Preferred Brand $25.00$75.00None
VARIZIG 125 UNIT/1.2 ML VIAL   5 Specialty Tier 25%N/ANone
VASCEPA 0.5 GM CAPSULE   3 Preferred Brand $25.00$75.00None
VASCEPA 1 GM CAPSULE   3 Preferred Brand $25.00$75.00None
VELTASSA 16.8 GM POWDER PACKET   3 Preferred Brand $25.00$75.00None
VELTASSA 25.2 GM POWDER PACKET   3 Preferred Brand $25.00$75.00None
VELTASSA 8.4 GM POWDER PACKET   3 Preferred Brand $25.00$75.00None
VEMLIDY 25 MG TABLET   5 Specialty Tier 25%N/ANone
VENCLEXTA 10 MG TABLET   4 Non-Preferred Drug 43%N/AP Q:60
/30Days
VENCLEXTA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
VENCLEXTA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VENCLEXTA STARTING PACK   5 Specialty Tier 25%N/AP Q:42
/30Days
VENLAFAXINE HCL 100 MG TABLET [Effexor]   2* Generic $2.00$6.00Q:90
/30Days
VENLAFAXINE HCL 25 MG TABLET [Effexor]   2* Generic $2.00$6.00Q:90
/30Days
VENLAFAXINE HCL 37.5 MG TABLET [Effexor]   2* Generic $2.00$6.00Q:90
/30Days
VENLAFAXINE HCL 50 MG TABLET [Effexor]   2* Generic $2.00$6.00Q:90
/30Days
VENLAFAXINE HCL 75 MG TABLET [Effexor]   2* Generic $2.00$6.00Q:90
/30Days
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR]   2* Generic $2.00$6.00Q:30
/30Days
VENLAFAXINE HCL ER 37.5 MG CAPSULE ER 24H [Effexor XR]   2* Generic $2.00$6.00Q:30
/30Days
VENLAFAXINE HCL ER 75 MG CAPSULE ER 24H [Effexor XR]   2* Generic $2.00$6.00Q:90
/30Days
VERAPAMIL 120 MG TABLET [Calan]   1* Preferred Generic $0.00$0.00None
VERAPAMIL 120MG CAPSULE PELLET   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERAPAMIL 180MG CAPSULE PELLET   2* Generic $2.00$6.00None
VERAPAMIL 240MG CAPSULE PELLET   2* Generic $2.00$6.00None
VERAPAMIL 40 MG TABLET [Isoptin SR]   1* Preferred Generic $0.00$0.00None
VERAPAMIL 80 MG TABLET   1* Preferred Generic $0.00$0.00None
VERAPAMIL ER 120 MG TABLET   2* Generic $2.00$6.00None
VERAPAMIL ER 180 MG TABLET   2* Generic $2.00$6.00None
VERAPAMIL ER 240 MG TABLET   2* Generic $2.00$6.00None
VERAPAMIL ER PM 100 MG CAPSULE 24H PCT [Verelan PM]   2* Generic $2.00$6.00None
VERAPAMIL ER PM 200 MG CAPSULE 24H PCT [Verelan PM]   2* Generic $2.00$6.00None
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM]   2* Generic $2.00$6.00None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERSACLOZ 50 MG/ML ORAL SUSPENSION   5 Specialty Tier 25%N/ANone
VERZENIO 100 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
VERZENIO 150 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
VERZENIO 200 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
VERZENIO 50 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
VICTOZA 3-PAK 18 MG/3 ML PEN   3 Preferred Brand $25.00$75.00P Q:9
/30Days
VIENVA-28 TABLET [Vienva]   4 Non-Preferred Drug 43%N/ANone
VIGABATRIN 500 MG POWDER PACKET [VIGADRONE]   5 Specialty Tier 25%N/AP Q:180
/30Days
VIGABATRIN 500 MG TABLET [Sabril]   5 Specialty Tier 25%N/AP Q:180
/30Days
VIGADRONE 500 MG POWDER PACKET   5 Specialty Tier 25%N/AP Q:180
/30Days
VIIBRYD 10-20 MG STARTER PACK   3 Preferred Brand $25.00$75.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $25.00$75.00Q:30
/30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $25.00$75.00Q:30
/30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $25.00$75.00Q:30
/30Days
VIMPAT 10 MG/ML SOLUTION   4 Non-Preferred Drug 43%N/AQ:1200
/30Days
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 43%N/AQ:60
/30Days
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 43%N/AQ:60
/30Days
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 43%N/AQ:60
/30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 43%N/AQ:60
/30Days
VIOKACE 10,440-39,150 UNITS TB   4 Non-Preferred Drug 43%N/ANone
VIOKACE 20,880-78,300 UNITS TB   4 Non-Preferred Drug 43%N/ANone
VIRACEPT 250MG TABLET   4 Non-Preferred Drug 43%N/AQ:270
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIRACEPT 625MG TABLET   4 Non-Preferred Drug 43%N/AQ:120
/30Days
VIREAD 150 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
VIREAD 200 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
VIREAD 250 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
VIREAD POWDER   5 Specialty Tier 25%N/AQ:225
/30Days
VITRAKVI 100 MG CAPSULE   4 Non-Preferred Drug 43%N/AP Q:60
/30Days
VITRAKVI 20 MG/ML SOLUTION   4 Non-Preferred Drug 43%N/AP Q:300
/30Days
VITRAKVI 25 MG CAPSULE   4 Non-Preferred Drug 43%N/AP Q:180
/30Days
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL   5 Specialty Tier 25%N/ANone
VIZIMPRO 15 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
VIZIMPRO 30 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIZIMPRO 45 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
VORICONAZOLE 200 MG TABLET [VFEND]   5 Specialty Tier 25%N/ANone
VORICONAZOLE 200 MG VIAL   4 Non-Preferred Drug 43%N/AP
VORICONAZOLE 40 MG/ML ORAL SUSPENSION [VFEND]   5 Specialty Tier 25%N/ANone
VORICONAZOLE 50 MG TABLET [VFEND]   5 Specialty Tier 25%N/ANone
VOTRIENT 200 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
VRAYLAR 1.5 MG CAP   4 Non-Preferred Drug 43%N/AQ:30
/30Days
VRAYLAR 1.5 MG-3 MG PACK   4 Non-Preferred Drug 43%N/AQ:7
/30Days
VRAYLAR 3 MG CAP   4 Non-Preferred Drug 43%N/AQ:30
/30Days
VRAYLAR 4.5 MG CAP   4 Non-Preferred Drug 43%N/AQ:30
/30Days
VRAYLAR 6 MG CAP   4 Non-Preferred Drug 43%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VYLIBRA 28 TABLET   4 Non-Preferred Drug 43%N/ANone
VYNDAMAX 61 MG CAPSULE   4 Non-Preferred Drug 43%N/AP

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.