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2022 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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Mutual of Omaha Rx Plus (PDP) (S7126-031-0)
Tier 1 (137)
Tier 2 (606)
Tier 3 (655)
Tier 4 (1108)
Tier 5 (492)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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Cick on the first letter of your drug name to browse the 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 
2022 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Plus (PDP) (S7126-031-0)
Benefit Details           
The Mutual of Omaha Rx Plus (PDP) (S7126-031-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION [Ziagen]   3 Preferred Brand 17%17%Q:900
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Drug 42%N/AP
ABILIFY MAINTENA ER 300 MG SYRINGE   4 Non-Preferred Drug 42%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   4 Non-Preferred Drug 42%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Drug 42%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   4 Non-Preferred Drug 42%N/AQ:1
/28Days
ABIRATERONE 500 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 42%N/AP Q:60
/30Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 42%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 42%N/ANone
ACARBOSE 100 MG TABLET [Precose]   2 Generic $3.00$9.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   2 Generic $3.00$9.00Q:360
/30Days
ACARBOSE 50 MG TABLET [Precose]   2 Generic $3.00$9.00Q:180
/30Days
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2 Generic $3.00$9.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2 Generic $3.00$9.00None
ACETAMINOP-CODEINE 120-12 MG/5   2 Generic $3.00$9.00Q:4500
/30Days
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand 17%17%Q:360
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   3 Preferred Brand 17%17%Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand 17%17%Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand 17%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250 MG TABLET [Diamox]   3 Preferred Brand 17%17%None
ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels]   4 Non-Preferred Drug 42%N/ANone
ACETIC ACID 2% EAR SOLUTION [VoSoL]   3 Preferred Brand 17%17%None
ACETYLCYSTEINE 10% VIAL   2 Generic $3.00$9.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2 Generic $3.00$9.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 42%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 42%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 42%N/ANone
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand 17%17%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/AP
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 42%N/ANone
ACYCLOVIR 400 MG TABLET   2 Generic $3.00$9.00None
ACYCLOVIR 5% OINTMENT [Zovirax]   4 Non-Preferred Drug 42%N/AP Q:30
/30Days
ACYCLOVIR 800 MG TABLET   2 Generic $3.00$9.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 42%N/AP
ADACEL TDAP SYRINGE   3 Preferred Brand 17%17%None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand 17%17%None
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand 17%17%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand 17%17%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand 17%17%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand 17%17%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 17%17%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 17%17%Q:12
/30Days
AFINITOR 10 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AP Q:150
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand 17%17%P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand 17%17%P Q:1
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 25%N/ANone
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2 Generic $3.00$9.00P
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 17%17%Q:17
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 17%17%Q:36
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 17%17%Q:13
/30Days
ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb]   2 Generic $3.00$9.00P
ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB   2 Generic $3.00$9.00P
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2 Generic $3.00$9.00P
ALBUTEROL SULF 2 MG/5 ML SYRUP   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 2 MG TABLET   4 Non-Preferred Drug 42%N/ANone
ALBUTEROL SULFATE 4 MG TABLET   4 Non-Preferred Drug 42%N/ANone
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   2 Generic $3.00$9.00None
ALCLOMETASONE DIPRO 0.05% CREAM   4 Non-Preferred Drug 42%N/ANone
ALECENSA 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
ALLOPURINOL 100 MG TABLET [Zyloprim]   1 Preferred Generic $1.00$3.00None
ALLOPURINOL 300 MG TABLET [Zyloprim]   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 25%N/ANone
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 25%N/ANone
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand 17%17%None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 25%N/AP Q:30
/30Days
ALYACEN 1-35-28 TABLET   4 Non-Preferred Drug 42%N/ANone
AMANTADINE 100 MG CAPSULE [Symmetrel]   3 Preferred Brand 17%17%None
AMANTADINE 100 MG TABLET   3 Preferred Brand 17%17%None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBISOME 50MG VIAL   5 Specialty Tier 25%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 42%N/AP
AMILORIDE HCL 5 MG TABLET [Midamor]   3 Preferred Brand 17%17%None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2 Generic $3.00$9.00None
AMIODARONE HCL 100 MG TABLET [Pacerone]   4 Non-Preferred Drug 42%N/ANone
AMIODARONE HCL 200 MG TABLET [Pacerone]   2 Generic $3.00$9.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   4 Non-Preferred Drug 42%N/ANone
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   2 Generic $3.00$9.00P
AMITRIPTYLINE HCL 100 MG TABLET   2 Generic $3.00$9.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TABLET   2 Generic $3.00$9.00P
AMITRIPTYLINE HCL 25 MG TABLET [Elavil]   2 Generic $3.00$9.00P
AMITRIPTYLINE HCL 50 MG TABLET   2 Generic $3.00$9.00P
AMITRIPTYLINE HCL 75 MG TABLET   2 Generic $3.00$9.00P
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1 Preferred Generic $1.00$3.00None
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   2 Generic $3.00$9.00None
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   2 Generic $3.00$9.00None
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   2 Generic $3.00$9.00None
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   2 Generic $3.00$9.00None
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   2 Generic $3.00$9.00None
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   2 Generic $3.00$9.00None
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   2 Generic $3.00$9.00None
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   2 Generic $3.00$9.00None
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   2 Generic $3.00$9.00None
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   2 Generic $3.00$9.00None
AMMONIUM LACTATE 12% LOTION   2 Generic $3.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2 Generic $3.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $3.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $3.00$9.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   4 Non-Preferred Drug 42%N/ANone
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   3 Preferred Brand 17%17%None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $3.00$9.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $3.00$9.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $3.00$9.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 42%N/ANone
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug 42%N/ANone
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug 42%N/ANone
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug 42%N/ANone
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125 MG/5 ML SUSP   2 Generic $3.00$9.00None
AMOXICILLIN 125MG CHEWABLE TABLET   2 Generic $3.00$9.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   2 Generic $3.00$9.00None
AMOXICILLIN 250 MG CHEWABLE TABLET   2 Generic $3.00$9.00None
AMOXICILLIN 250 MG CAPSULE [Trimox]   2 Generic $3.00$9.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   2 Generic $3.00$9.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2 Generic $3.00$9.00None
AMOXICILLIN 500 MG CAPSULE [Trimox]   2 Generic $3.00$9.00None
AMOXICILLIN 500 MG TABLET   2 Generic $3.00$9.00None
AMOXICILLIN 875 MG TABLET   2 Generic $3.00$9.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 42%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN 1 GM VIAL   4 Non-Preferred Drug 42%N/AP
AMPICILLIN 10 GM BOTTLE VIAL   4 Non-Preferred Drug 42%N/AP
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 42%N/AP
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 42%N/AP
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2 Generic $3.00$9.00None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   4 Non-Preferred Drug 42%N/AP
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Non-Preferred Drug 42%N/AP
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin]   3 Preferred Brand 17%17%None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 17%17%None
ANASTROZOLE 1 MG TABLET   2 Generic $3.00$9.00None
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand 17%17%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/AP Q:60
/30Days
Apraclonidine 5 MG/ML Ophthalmic Solution   4 Non-Preferred Drug 42%N/ANone
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 42%N/AP
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 42%N/AP
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 42%N/AP
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 42%N/AP
APTIOM 200 MG TABLET   4 Non-Preferred Drug 42%N/AQ:180
/30Days
APTIOM 400 MG TABLET   4 Non-Preferred Drug 42%N/AQ:90
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 42%N/AQ:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 42%N/AQ:60
/30Days
APTIVUS 250MG CAPSULE   4 Non-Preferred Drug 42%N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARCALYST 220 MG VIAL   5 Specialty Tier 25%N/AP
ARIKAYCE 590 MG/8.4 ML VIAL-NEB   4 Non-Preferred Drug 42%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 42%N/ANone
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 17%17%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 17%17%Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand 17%17%Q:30
/30Days
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1 Preferred Generic $1.00$3.00None
ATENOLOL 25 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL 50 MG TABLET [Tenormin]   1 Preferred Generic $1.00$3.00None
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $3.00$9.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $3.00$9.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron]   5 Specialty Tier 25%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 42%N/ANone
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug 42%N/ANone
ATROVENT HFA AER 17MCG   3 Preferred Brand 17%17%Q:26
/30Days
AUBRA EQ-28 TABLET [Vienva]   4 Non-Preferred Drug 42%N/ANone
AYVAKIT 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AYVAKIT 25 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
AYVAKIT 300 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AYVAKIT 50 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AZATHIOPRINE 50 MG TABLET [Imuran]   2 Generic $3.00$9.00P
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand 17%17%Q:60
/30Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand 17%17%Q:60
/30Days
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   4 Non-Preferred Drug 42%N/ANone
AZITHROMYCIN 1 GM POWDER PACKET   3 Preferred Brand 17%17%None
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   4 Non-Preferred Drug 42%N/ANone
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   4 Non-Preferred Drug 42%N/ANone
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2 Generic $3.00$9.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 500 MG TABLET   2 Generic $3.00$9.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $3.00$9.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2 Generic $3.00$9.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   4 Non-Preferred Drug 42%N/AP
AZTREONAM 2 GM VIAL [Azactam]   4 Non-Preferred Drug 42%N/AP
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 42%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2022 Medicare Part D Mutual of Omaha Rx Plus (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 $480 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 $4,430) 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 2022 )

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.









Tips & Disclaimers
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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.