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Mutual of Omaha Rx Premier (PDP) (S7126-080-0)
Tier 1 (137)
Tier 2 (604)
Tier 3 (721)
Tier 4 (1078)
Tier 5 (507)
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 Premier (PDP) (S7126-080-0)
Benefit Details           
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below.
The Mutual of Omaha Rx Premier (PDP) (S7126-080-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 11 which includes: FL
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]   4 Non-Preferred Drug 44%N/AQ:900
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Drug 44%N/AP
ABILIFY MAINTENA ER 300 MG SYRINGE   4 Non-Preferred Drug 44%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   4 Non-Preferred Drug 44%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Drug 44%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   4 Non-Preferred Drug 44%N/AQ:1
/28Days
ABIRATERONE 500 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 44%N/AP Q:60
/30Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 44%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 44%N/ANone
ACARBOSE 100 MG TABLET [Precose]   2* Generic $13.00$39.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   2* Generic $13.00$39.00Q:360
/30Days
ACARBOSE 50 MG TABLET [Precose]   2* Generic $13.00$39.00Q:180
/30Days
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2* Generic $13.00$39.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2* Generic $13.00$39.00None
ACETAMINOP-CODEINE 120-12 MG/5   2* Generic $13.00$39.00Q:4500
/30Days
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand 23%23%Q:360
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   3 Preferred Brand 23%23%Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand 23%23%Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand 23%23%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 23%23%None
ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels]   4 Non-Preferred Drug 44%N/ANone
ACETIC ACID 2% EAR SOLUTION [VoSoL]   3 Preferred Brand 23%23%None
ACETYLCYSTEINE 10% VIAL   2* Generic $13.00$39.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2* Generic $13.00$39.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 44%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 44%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 44%N/ANone
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand 23%23%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/AP
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2* Generic $13.00$39.00None
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 44%N/ANone
ACYCLOVIR 400 MG TABLET   2* Generic $13.00$39.00None
ACYCLOVIR 5% OINTMENT [Zovirax]   4 Non-Preferred Drug 44%N/AP Q:30
/30Days
ACYCLOVIR 800 MG TABLET   2* Generic $13.00$39.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 44%N/AP
ADACEL TDAP SYRINGE   3 Preferred Brand 23%23%None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand 23%23%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 23%23%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand 23%23%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand 23%23%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand 23%23%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 23%23%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 23%23%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 23%23%P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand 23%23%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 $13.00$39.00P
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 23%23%Q:36
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 23%23%Q:13
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 23%23%Q:17
/30Days
ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb]   2* Generic $13.00$39.00P
ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB   2* Generic $13.00$39.00P
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2* Generic $13.00$39.00P
ALBUTEROL SULF 2 MG/5 ML SYRUP   2* Generic $13.00$39.00None
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 44%N/ANone
ALBUTEROL SULFATE 4 MG TABLET   4 Non-Preferred Drug 44%N/ANone
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   2* Generic $13.00$39.00None
ALCLOMETASONE DIPRO 0.05% CREAM   4 Non-Preferred Drug 44%N/ANone
ALECENSA 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $13.00$39.00Q:30
/30Days
ALLOPURINOL 100 MG TABLET [Zyloprim]   1* Preferred Generic $0.00$0.00None
ALLOPURINOL 300 MG TABLET [Zyloprim]   1* Preferred Generic $0.00$0.00None
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 23%23%None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   3 Preferred Brand 23%23%Q:90
/30Days
ALPRAZOLAM 0.5 MG TABLET   3 Preferred Brand 23%23%Q:90
/30Days
ALPRAZOLAM 1 MG TABLET   3 Preferred Brand 23%23%Q:90
/30Days
ALPRAZOLAM 2 MG TABLET   3 Preferred Brand 23%23%Q:150
/30Days
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALYACEN 1-35-28 TABLET   4 Non-Preferred Drug 44%N/ANone
AMANTADINE 100 MG CAPSULE [Symmetrel]   3 Preferred Brand 23%23%None
AMANTADINE 100 MG TABLET   3 Preferred Brand 23%23%None
AMANTADINE 50 MG/5 ML SOLUTION   2* Generic $13.00$39.00None
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 44%N/AP
AMILORIDE HCL 5 MG TABLET [Midamor]   3 Preferred Brand 23%23%None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2* Generic $13.00$39.00None
AMIODARONE HCL 100 MG TABLET [Pacerone]   4 Non-Preferred Drug 44%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HCL 200 MG TABLET [Pacerone]   2* Generic $13.00$39.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   4 Non-Preferred Drug 44%N/ANone
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   2* Generic $13.00$39.00P
AMITRIPTYLINE HCL 100 MG TABLET   2* Generic $13.00$39.00P
AMITRIPTYLINE HCL 150 MG TABLET   2* Generic $13.00$39.00P
AMITRIPTYLINE HCL 25 MG TABLET [Elavil]   2* Generic $13.00$39.00P
AMITRIPTYLINE HCL 50 MG TABLET   2* Generic $13.00$39.00P
AMITRIPTYLINE HCL 75 MG TABLET   2* Generic $13.00$39.00P
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   2* Generic $13.00$39.00None
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   2* Generic $13.00$39.00None
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   2* Generic $13.00$39.00None
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   2* Generic $13.00$39.00None
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   2* Generic $13.00$39.00None
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   2* Generic $13.00$39.00None
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   2* Generic $13.00$39.00None
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   2* Generic $13.00$39.00None
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   2* Generic $13.00$39.00None
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   2* Generic $13.00$39.00None
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   2* Generic $13.00$39.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% LOTION   2* Generic $13.00$39.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2* Generic $13.00$39.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2* Generic $13.00$39.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 44%N/ANone
AMOX-CLAV 200-28.5 MG/5 ML SUS   2* Generic $13.00$39.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   4 Non-Preferred Drug 44%N/ANone
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   3 Preferred Brand 23%23%None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $13.00$39.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2* Generic $13.00$39.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $13.00$39.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 44%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug 44%N/ANone
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug 44%N/ANone
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug 44%N/ANone
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug 44%N/ANone
AMOXICILLIN 125 MG/5 ML SUSP   2* Generic $13.00$39.00None
AMOXICILLIN 125MG CHEWABLE TABLET   2* Generic $13.00$39.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $13.00$39.00None
AMOXICILLIN 250 MG CHEWABLE TABLET   2* Generic $13.00$39.00None
AMOXICILLIN 250 MG CAPSULE [Trimox]   2* Generic $13.00$39.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   2* Generic $13.00$39.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $13.00$39.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500 MG CAPSULE [Trimox]   2* Generic $13.00$39.00None
AMOXICILLIN 500 MG TABLET   2* Generic $13.00$39.00None
AMOXICILLIN 875 MG TABLET   2* Generic $13.00$39.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 44%N/AP
AMPICILLIN 1 GM VIAL   4 Non-Preferred Drug 44%N/AP
AMPICILLIN 10 GM BOTTLE VIAL   4 Non-Preferred Drug 44%N/AP
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 44%N/AP
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 44%N/AP
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2* Generic $13.00$39.00None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   4 Non-Preferred Drug 44%N/AP
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Non-Preferred Drug 44%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin]   3 Preferred Brand 23%23%None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 23%23%None
ANASTROZOLE 1 MG TABLET   2* Generic $13.00$39.00None
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand 23%23%Q:60
/30Days
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 44%N/ANone
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 44%N/AP
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 44%N/AP
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 44%N/AP
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 44%N/AP
APTIOM 200 MG TABLET   4 Non-Preferred Drug 44%N/AQ:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 400 MG TABLET   4 Non-Preferred Drug 44%N/AQ:90
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 44%N/AQ:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 44%N/AQ:60
/30Days
APTIVUS 250MG CAPSULE   4 Non-Preferred Drug 44%N/AQ:120
/30Days
ARCALYST 220 MG VIAL   5 Specialty Tier 25%N/AP
ARIKAYCE 590 MG/8.4 ML VIAL-NEB   4 Non-Preferred Drug 44%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 44%N/ANone
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 23%23%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 23%23%Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand 23%23%Q:30
/30Days
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1* Preferred Generic $0.00$0.00None
ATENOLOL 25 MG TABLET   1* Preferred Generic $0.00$0.00None
ATENOLOL 50 MG TABLET [Tenormin]   1* Preferred Generic $0.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2* Generic $13.00$39.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2* Generic $13.00$39.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 44%N/AQ:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q: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 44%N/ANone
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug 44%N/ANone
ATROVENT HFA AER 17MCG   3 Preferred Brand 23%23%Q:26
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBRA EQ-28 TABLET [Vienva]   4 Non-Preferred Drug 44%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
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 $13.00$39.00P
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand 23%23%Q:60
/30Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand 23%23%Q:60
/30Days
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   4 Non-Preferred Drug 44%N/ANone
AZITHROMYCIN 1 GM POWDER PACKET   3 Preferred Brand 23%23%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   4 Non-Preferred Drug 44%N/ANone
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   4 Non-Preferred Drug 44%N/ANone
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2* Generic $13.00$39.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2* Generic $13.00$39.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $13.00$39.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $13.00$39.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2* Generic $13.00$39.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   4 Non-Preferred Drug 44%N/AP
AZTREONAM 2 GM VIAL [Azactam]   4 Non-Preferred Drug 44%N/AP
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 44%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2022 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 $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.