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Mutual of Omaha Rx Premier (PDP) (S7126-101-0)
Tier 1 (138)
Tier 2 (681)
Tier 3 (722)
Tier 4 (937)
Tier 5 (515)
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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2021 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Premier (PDP) (S7126-101-0)
Benefit Details           
This plan covers select insulin pay $25 copay.
See individual insulin cost-sharing below.
The Mutual of Omaha Rx Premier (PDP) (S7126-101-0)
Formulary Drugs Starting with the Letter H

in CMS PDP Region 32 which includes: CA
Plan Monthly Premium: $24.00 Deductible: $445 Qualifies for LIS: No
Drugs Starting with Letter H

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
HAILEY 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20]   4 Non-Preferred Drug 44%N/ANone
HALOBETASOL PROP 0.05% CREAM   4 Non-Preferred Drug 44%N/ANone
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE   4 Non-Preferred Drug 44%N/ANone
HALOPERIDOL 0.5 MG TABLET   2* Generic $2.00$6.00None
HALOPERIDOL 1 MG TABLET [Haldol]   2* Generic $2.00$6.00None
HALOPERIDOL 10 MG TABLET   2* Generic $2.00$6.00None
HALOPERIDOL 20MG TABLET (100 CT)   2* Generic $2.00$6.00None
HALOPERIDOL 2MG TABLET (100 CT)   2* Generic $2.00$6.00None
HALOPERIDOL 5 MG TABLET [Haldol]   2* Generic $2.00$6.00None
HALOPERIDOL DEC 100 MG/ML AMPUL [Haldol Decanoate]   4 Non-Preferred Drug 44%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HALOPERIDOL DEC 100 MG/ML VIAL   4 Non-Preferred Drug 44%N/ANone
HALOPERIDOL DEC 250 MG/5 ML VIAL [Haldol Decanoate]   4 Non-Preferred Drug 44%N/ANone
HALOPERIDOL DECAN 50 MG/ML AMPUL [Haldol Decanoate]   4 Non-Preferred Drug 44%N/ANone
HALOPERIDOL LAC 2 MG/ML CONC   2* Generic $2.00$6.00None
HALOPERIDOL LAC 5 MG/ML VIAL   2* Generic $2.00$6.00None
HARVONI 33.75-150 MG PELLET PACKET   5 Specialty Tier 25%N/AP Q:28
/28Days
HARVONI 45-200 MG PELLET PACKET   5 Specialty Tier 25%N/AP
HARVONI 90-400 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
HAVRIX 1,440 UNITS/ML SYRINGE   3 Preferred Brand 23%23%None
HAVRIX HEPATITIS A VACCINE INJECTION   3 Preferred Brand 23%23%None
HEPARIN 30,000 UNIT/30 ML VIAL   3 Preferred Brand 23%23%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HEPARIN SOD 5,000 UNIT/ML VIAL   3 Preferred Brand 23%23%None
HEPARIN SODIUM INJECTION   3 Preferred Brand 23%23%None
HEPARIN SODIUM INJECTION   3 Preferred Brand 23%23%None
HEPATAMINE INJECTION 8%   3 Preferred Brand 23%23%P
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax]   3 Preferred Brand 23%23%P
HETLIOZ 20 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
HIBERIX VACCINE WITH DILUENT   3 Preferred Brand 23%23%None
HUMALOG 100 UNIT/ML VIAL   3 Preferred Brand $25.0023%None
HUMALOG 100 UNITS/ML CARTRIDGE   3 Preferred Brand $25.0023%None
HUMALOG JR 100 UNIT/ML KWIKPEN   3 Preferred Brand $25.0023%None
HUMALOG KWIKPEN INJECTION   3 Preferred Brand $25.0023%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMALOG MIX 50/50 VIAL   3 Preferred Brand $25.0023%None
HUMALOG MIX 75/25 VIAL   3 Preferred Brand $25.0023%None
HUMALOG MIX KWIKPEN INJECTION   3 Preferred Brand $25.0023%None
HUMALOG MIX KWIKPEN INJECTION SUSPENSION   3 Preferred Brand $25.0023%None
HUMIRA 10 MG/0.1 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
Humira 2 KIT per CARTON / 1 KIT in 1 KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 20 MG/0.2 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
HUMIRA 40 MG/0.4 ML PEN IJ KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 40 MG/0.4 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 40 MG/0.8 ML PEN   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:3
/180Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/180Days
HUMIRA PEN KIT 40MG-70% 1 PKGCOM   5 Specialty Tier 25%N/AP Q:6
/180Days
HUMIRA PEN PSORIASIS-UVEITIS   5 Specialty Tier 25%N/AP Q:4
/180Days
HUMIRA(CF) PEN 80 MG/0.8 ML PEN IJ KIT   5 Specialty Tier 25%N/AP Q:2
/28Days
HUMIRA(CF) PEN CRHN-UC-HS 80MG PEN IJ KIT   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMIRA(CF) PEN PEDI UC 80 MG PEN IJ KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA(CF) PEN PS-UV-AHS 80-40 PEN IJ KIT   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMULIN 70/30 KWIKPEN   3 Preferred Brand $25.0023%None
HUMULIN 70/30 VIAL   3 Preferred Brand $25.0023%None
HUMULIN N 100 UNITS/ML KWIKPEN   3 Preferred Brand $25.0023%None
HUMULIN N 100U/ML VIAL   3 Preferred Brand $25.0023%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMULIN R 100U/ML VIAL   3 Preferred Brand $25.0023%None
HUMULIN R 500 UNITS/ML KWIKPEN   4 Non-Preferred Drug 44%N/ANone
HUMULIN R 500U/ML VIAL   4 Non-Preferred Drug 44%N/ANone
HYDRALAZINE 10 MG TABLET [Apresoline]   2* Generic $2.00$6.00None
HYDRALAZINE 100 MG TABLET [Apresoline]   2* Generic $2.00$6.00None
HYDRALAZINE 25 MG TABLET   2* Generic $2.00$6.00None
HYDRALAZINE 50 MG TABLET   2* Generic $2.00$6.00None
Hydrochlorothiazide 12.5 MG Oral Capsule   1* Preferred Generic $0.00$0.00None
HYDROCHLOROTHIAZIDE 12.5 MG TABLET   1* Preferred Generic $0.00$0.00None
HYDROCHLOROTHIAZIDE 25 MG TABLET   1* Preferred Generic $0.00$0.00None
HYDROCHLOROTHIAZIDE 50 MG TABLET [Zide]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCODON-ACETAMINOPH 7.5-325   3 Preferred Brand 23%23%Q:360
/30Days
HYDROCODON-ACETAMINOPHEN 5-325   3 Preferred Brand 23%23%Q:360
/30Days
HYDROCODONE-ACETAMIN 10-325 MG TABLET [Norco]   3 Preferred Brand 23%23%Q:360
/30Days
HYDROCODONE-ACETAMN 7.5-325/15 SOLUTION [Hycet]   4 Non-Preferred Drug 44%N/AQ:5550
/30Days
HYDROCODONE-IBUPROFEN 7.5-200 TABLET [Vicoprofen]   3 Preferred Brand 23%23%Q:50
/30Days
HYDROCORTISON-ACETIC ACID SOLUTION DROPS [VoSoL HC]   4 Non-Preferred Drug 44%N/ANone
HYDROCORTISONE 1% CREAM   2* Generic $2.00$6.00None
HYDROCORTISONE 10 MG TABLET [Hydrocortone]   3 Preferred Brand 23%23%None
HYDROCORTISONE 100 MG/60 ML   3 Preferred Brand 23%23%None
HYDROCORTISONE 2.5% CREAM (g) [Proctozone-HC]   2* Generic $2.00$6.00None
HYDROCORTISONE 2.5% LOTION   4 Non-Preferred Drug 44%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCORTISONE 2.5% OINTMENT   2* Generic $2.00$6.00None
HYDROCORTISONE 20 MG TABLET [Cortef]   3 Preferred Brand 23%23%None
HYDROCORTISONE 5 MG TABLET [Cortef]   3 Preferred Brand 23%23%None
HYDROCORTISONE VAL 0.2% CREAM (g) [Westcort]   2* Generic $2.00$6.00None
HYDROCORTISONE VAL 0.2% OINTMENT   4 Non-Preferred Drug 44%N/ANone
HYDROMORPHONE 1 MG/ML SOLUTION LIQUID [Dilaudid]   2* Generic $2.00$6.00Q:2400
/30Days
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP]   4 Non-Preferred Drug 44%N/AQ:240
/30Days
HYDROMORPHONE 2 MG TABLET [Dilaudid]   3 Preferred Brand 23%23%Q:180
/30Days
HYDROMORPHONE 4 MG TABLET [Dilaudid]   3 Preferred Brand 23%23%Q:180
/30Days
HYDROMORPHONE 50 MG/5 ML AMPUL [Dilaudid-HP]   4 Non-Preferred Drug 44%N/AQ:240
/30Days
HYDROMORPHONE 8 MG TABLET [Dilaudid]   3 Preferred Brand 23%23%Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROXYCHLOROQUINE 200 MG TABLET   3 Preferred Brand 23%23%None
HYDROXYUREA 500 MG CAPSULE   2* Generic $2.00$6.00None
HYDROXYZINE HCL 10 MG TABLET [Rezine]   2* Generic $2.00$6.00P
HYDROXYZINE HCL 25 MG TABLET [Atarax]   2* Generic $2.00$6.00P
HYDROXYZINE HCL 50 MG TABLET [Atarax]   2* Generic $2.00$6.00P

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D Mutual of Omaha Rx Premier (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 $445 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 $4,130) 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.

      * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 2021 )

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.