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Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
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2022 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
Benefit Details           
The Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter D

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
D5%-1/2NS-KCL 10 MEQ/L IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
D5%-1/2NS-KCL 30 MEQ/L IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
D5%-1/2NS-KCL 40 MEQ/L IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 25%N/AP Q:60
/30Days
DALIRESP 250 MCG TABLET   4 Non-Preferred Drug 41%N/AP Q:30
/30Days
DALIRESP 500 MCG TABLET   4 Non-Preferred Drug 41%N/AP Q:30
/30Days
DANAZOL 100 MG CAPSULE [Danocrine]   4 Non-Preferred Drug 41%N/ANone
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 41%N/ANone
DANTROLENE SODIUM 100MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DANTROLENE SODIUM 25MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DANTROLENE SODIUM 50MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DAPSONE 100 MG TABLET   3 Preferred Brand 18%18%None
DAPSONE 25 MG TABLET   3 Preferred Brand 18%18%None
DAPTACEL DTAP VACCINE VIAL   3 Preferred Brand 18%18%None
DAPTOMYCIN 350 MG VIAL [Cubicin RF]   5 Specialty Tier 25%N/ANone
DAPTOMYCIN 500 MG VIAL [Cubicin RF]   5 Specialty Tier 25%N/ANone
DAURISMO 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
DAURISMO 25 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERIPRONE 1,000 MG TABLET (3X/DY) [Ferriprox]   5 Specialty Tier 25%N/AP
DEFERIPRONE 500 MG TABLET [Ferriprox]   5 Specialty Tier 25%N/AP
DELSTRIGO 100-300-300 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DENAVIR 1% CREAM (g)   4 Non-Preferred Drug 41%N/AQ:5
/30Days
DESCOVY 200-25 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
DESIPRAMINE 10 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 100 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 150 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 25 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 50 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE 75 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESMOPRESSIN 10 MCG/0.1 ML SPR SPRAY/PUMP [Minirin]   4 Non-Preferred Drug 41%N/ANone
DESMOPRESSIN ACETATE 0.1 MG TABLET [DDAVP]   3 Preferred Brand 18%18%None
DESMOPRESSIN ACETATE 0.2 MG TABLET [DDAVP]   3 Preferred Brand 18%18%None
DESOGESTREL-EE 0.15-0.03 MG TABLET [Solia]   4 Non-Preferred Drug 41%N/ANone
DESONIDE 0.05% CREAM (G) [Tridesilon]   4 Non-Preferred Drug 41%N/ANone
DESONIDE 0.05% LOTION [LoKara]   4 Non-Preferred Drug 41%N/ANone
DESONIDE 0.05% OINTMENT [Tridesilon]   4 Non-Preferred Drug 41%N/ANone
DESOXIMETASONE 0.05% CREAM (G) [Topicort LP]   4 Non-Preferred Drug 41%N/ANone
DESOXIMETASONE 0.05% OINTMENT [Topicort LP]   4 Non-Preferred Drug 41%N/ANone
DESOXIMETASONE 0.25% CREAM   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESOXIMETASONE 0.25% OINTMENT [Topicort]   4 Non-Preferred Drug 41%N/ANone
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 41%N/ANone
DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DESVENLAFAXINE SUC ER 25 MG TABLET ER 24H [Pristiq]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DESVENLAFAXINE SUCCNT ER 50 MG TABLET ER 24H [Pristiq]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   3 Preferred Brand 18%18%None
DEXAMETHASONE 0.5 MG/5 ML ELIXIR [Decadron]   3 Preferred Brand 18%18%None
DEXAMETHASONE 0.5MG TABLET   2 Generic $3.00$9.00None
DEXAMETHASONE 0.75MG TABLET   2 Generic $3.00$9.00None
DEXAMETHASONE 1.5MG TABLET   2 Generic $3.00$9.00None
DEXAMETHASONE 1MG TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 2MG TABLET   2 Generic $3.00$9.00None
DEXAMETHASONE 4MG TABLET   2 Generic $3.00$9.00None
DEXAMETHASONE 6MG TABLET   2 Generic $3.00$9.00None
DEXILANT CAPSULES DELAYED RELEASE 30 MG   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXILANT DR 60 MG CAPSULE   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXTROAMP-AMPHET ER 10 MG CAPSULE ER 24H [Adderall XR]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXTROAMP-AMPHET ER 15 MG CAPSULE ER 24H [Adderall XR]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAPSULE ER 24H [Adderall XR]   4 Non-Preferred Drug 41%N/AQ:60
/30Days
DEXTROAMP-AMPHET ER 25 MG CAPSULE ER 24H [Mydayis]   4 Non-Preferred Drug 41%N/AQ:60
/30Days
DEXTROAMP-AMPHET ER 30 MG CAPSULE ER 24H [Adderall XR]   4 Non-Preferred Drug 41%N/AQ:60
/30Days
DEXTROAMP-AMPHET ER 5 MG CAPSULE ER 24H [Adderall XR]   4 Non-Preferred Drug 41%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMPHETAMINE 10 MG TABLET [Zenzedi]   3 Preferred Brand 18%18%None
DEXTROAMPHETAMINE 15 MG TABLET [Zenzedi]   3 Preferred Brand 18%18%None
DEXTROAMPHETAMINE 20 MG TABLET [Zenzedi]   3 Preferred Brand 18%18%None
DEXTROAMPHETAMINE 30 MG TABLET [Zenzedi]   3 Preferred Brand 18%18%None
DEXTROAMPHETAMINE 5 MG TABLET [Zenzedi]   3 Preferred Brand 18%18%None
DEXTROAMPHETAMINE ER 10 MG CAPSULE ER [Dexedrine Spansule]   4 Non-Preferred Drug 41%N/ANone
DEXTROAMPHETAMINE ER 15 MG CAPSULE ER [Dexedrine Spansule]   4 Non-Preferred Drug 41%N/ANone
DEXTROAMPHETAMINE ER 5 MG CAPSULE ER [Dexedrine Spansule]   4 Non-Preferred Drug 41%N/ANone
DEXTROSE 10%-1/4NS IV TUBEX   4 Non-Preferred Drug 41%N/ANone
DEXTROSE 10%-WATER IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
DEXTROSE 2.5%-1/2NS IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE 5%-0.2% NACL IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
DEXTROSE 5%-0.45% NACL IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
DEXTROSE 5%-0.9% NACL IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
DEXTROSE 5%-WATER IV SOLUTION PIGGYBACK PRT   4 Non-Preferred Drug 41%N/ANone
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Drug 41%N/ANone
DIACOMIT 250 MG CAPSULE   4 Non-Preferred Drug 41%N/AP
DIACOMIT 250 MG POWDER PACK   4 Non-Preferred Drug 41%N/AP
DIACOMIT 500 MG CAPSULE   4 Non-Preferred Drug 41%N/AP
DIACOMIT 500 MG POWDER PACK   4 Non-Preferred Drug 41%N/AP
DIAZEPAM 10 MG RECTAL GEL SYST KIT [Diastat]   3 Preferred Brand 18%18%None
DIAZEPAM 10 MG TABLET [Valium]   2 Generic $3.00$9.00P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIAZEPAM 2 MG TABLET [Valium]   2 Generic $3.00$9.00P Q:120
/30Days
DIAZEPAM 2.5 MG RECTAL GEL SYST KIT [Diastat]   3 Preferred Brand 18%18%None
DIAZEPAM 20 MG RECTAL GEL SYST KIT [Diastat]   3 Preferred Brand 18%18%None
DIAZEPAM 5 MG TABLET [Valium]   2 Generic $3.00$9.00P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   2 Generic $3.00$9.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2 Generic $3.00$9.00P Q:240
/30Days
DIAZOXIDE 50 MG/ML ORAL SUSPENSION [Proglycem]   4 Non-Preferred Drug 41%N/ANone
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2 Generic $3.00$9.00None
DICLOFENAC 1.5% TOPICAL SOLUTION DROPS [VOPAC MDS]   4 Non-Preferred Drug 41%N/AQ:300
/28Days
DICLOFENAC POT 50 MG TABLET [Cataflam]   2 Generic $3.00$9.00None
DICLOFENAC SOD EC 75 MG TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC SODIUM 1% GEL [Voltaren Gel]   3 Preferred Brand 18%18%Q:1000
/28Days
DICLOXACILLIN 250MG CAPSULE   2 Generic $3.00$9.00None
DICLOXACILLIN SODIUM 500MG CAPSULE   2 Generic $3.00$9.00None
DICYCLOMINE 10 MG CAPSULE [Bentyl]   2 Generic $3.00$9.00None
DICYCLOMINE 20 MG TABLET [Bentyl]   2 Generic $3.00$9.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   4 Non-Preferred Drug 41%N/ANone
DIFLUNISAL 500 MG TABLET [Dolobid]   4 Non-Preferred Drug 41%N/ANone
DIGITEK 125 MCG TABLET   3 Preferred Brand 18%18%None
DIGITEK 250 MCG TABLET   3 Preferred Brand 18%18%None
DIGOX 125 MCG TABLET [Lanoxin]   2 Generic $3.00$9.00None
DIGOX 250 MCG TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   4 Non-Preferred Drug 41%N/ANone
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $3.00$9.00None
DIGOXIN 250 MCG TABLET [Lanoxin]   2 Generic $3.00$9.00None
DIGOXIN 62.5 MCG TABLET [Lanoxin]   2 Generic $3.00$9.00None
DIHYDROERGOTAMINE 4 MG/ML SPRAY   4 Non-Preferred Drug 41%N/AQ:8
/28Days
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 41%N/ANone
DILT XR 120 MG CAPSULE   3 Preferred Brand 18%18%None
DILT XR 180 MG CAPSULE   3 Preferred Brand 18%18%None
DILT XR 240 MG CAPSULE   3 Preferred Brand 18%18%None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $3.00$9.00None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 41%N/ANone
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 41%N/ANone
DILTIAZEM 24H ER(LA) 180 MG TABLET ER 24H [Matzim LA]   2 Generic $3.00$9.00None
DILTIAZEM 24H ER(LA) 240 MG TABLET ER 24H [Matzim LA]   2 Generic $3.00$9.00None
DILTIAZEM 24H ER(LA) 300 MG TABLET ER 24H [Matzim LA]   2 Generic $3.00$9.00None
DILTIAZEM 24H ER(LA) 360 MG TABLET ER 24H [Matzim LA]   2 Generic $3.00$9.00None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   2 Generic $3.00$9.00None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   2 Generic $3.00$9.00None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   2 Generic $3.00$9.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   2 Generic $3.00$9.00None
DILTIAZEM 24HR ER 360 MG CAPSULE SA 24H [Tiazac]   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 24HR ER 420 MG CAPSULE [Tiazac]   3 Preferred Brand 18%18%None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $3.00$9.00None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $3.00$9.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $3.00$9.00None
DIMETHYL FUMARATE 30D START PK CAPSULE DR [Tecfidera]   5 Specialty Tier 25%N/AP Q:120
/180Days
DIMETHYL FUMARATE DR 120 MG CAPSULE DR [Tecfidera]   5 Specialty Tier 25%N/AP Q:14
/30Days
DIMETHYL FUMARATE DR 240 MG CAPSULE DR [Tecfidera]   5 Specialty Tier 25%N/AP Q:60
/30Days
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand 18%18%None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand 18%18%None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand 18%18%None
DIPYRIDAMOLE 25 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIPYRIDAMOLE 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DIPYRIDAMOLE 75 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DISULFIRAM 250 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DISULFIRAM 500 MG TABLET [Antabuse]   4 Non-Preferred Drug 41%N/ANone
DIVALPROEX DR 125 MG CAPSULE SPRNK   4 Non-Preferred Drug 41%N/ANone
DIVALPROEX SOD DR 125 MG TABLET DR [Depakote]   2 Generic $3.00$9.00None
DIVALPROEX SOD DR 250 MG TABLET DR [Depakote]   2 Generic $3.00$9.00None
DIVALPROEX SOD DR 500 MG TABLET DR [Depakote]   2 Generic $3.00$9.00None
DIVALPROEX SOD ER 250 MG TABLET ER 24H [Depakote ER]   4 Non-Preferred Drug 41%N/ANone
DIVALPROEX SOD ER 500 MG TABLET ER 24H [Depakote ER]   4 Non-Preferred Drug 41%N/ANone
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 41%N/ANone
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 41%N/ANone
DOLISHALE 90-20 MCG TABLET [Lybrel]   4 Non-Preferred Drug 41%N/ANone
DONEPEZIL HCL 10 MG TABLET   2 Generic $3.00$9.00Q:69
/30Days
DONEPEZIL HCL 5 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
DONEPEZIL HCL ODT 10 MG TABLET   2 Generic $3.00$9.00Q:69
/30Days
DONEPEZIL HCL ODT 5 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
DORZOLAMIDE HCL 2% EYE DROPS [Trusopt]   2 Generic $3.00$9.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   2 Generic $3.00$9.00None
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF]   4 Non-Preferred Drug 41%N/ANone
DOTTI 0.025 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Drug 41%N/AP Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOTTI 0.0375 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Drug 41%N/AP Q:8
/28Days
DOTTI 0.05 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Drug 41%N/AP Q:8
/28Days
DOTTI 0.075 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Drug 41%N/AP Q:8
/28Days
DOTTI 0.1 MG PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Drug 41%N/AP Q:8
/28Days
DOVATO 50-300 MG TABLET   5 Specialty Tier 25%N/ANone
DOXAZOSIN MESYLATE 1 MG TABLET [Cardura]   2 Generic $3.00$9.00Q:30
/30Days
DOXAZOSIN MESYLATE 2 MG TABLET [Cardura]   2 Generic $3.00$9.00Q:30
/30Days
DOXAZOSIN MESYLATE 4 MG TABLET [Cardura]   2 Generic $3.00$9.00Q:30
/30Days
DOXAZOSIN MESYLATE 8 MG TABLET [Cardura]   2 Generic $3.00$9.00Q:60
/30Days
DOXEPIN 10 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 41%N/AP
DOXEPIN 10 MG/ML ORAL CONC [Sinequan]   4 Non-Preferred Drug 41%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN 100 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 41%N/AP
DOXEPIN 25 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 41%N/AP
DOXEPIN 50 MG CAPSULE [Sinequan]   4 Non-Preferred Drug 41%N/AP
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 41%N/AP
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 41%N/AP
DOXY 100 VIAL   4 Non-Preferred Drug 41%N/AP
doxycycline 25 mg/5 ml susp   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE 50 MG TABLET [TARGADOX]   3 Preferred Brand 18%18%None
DOXYCYCLINE HYCLATE 100 MG CAPSULE [Vibramycin]   3 Preferred Brand 18%18%None
DOXYCYCLINE HYCLATE 100 MG TABLET [Vibra-Tabs]   3 Preferred Brand 18%18%None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 50 MG CAPSULE   3 Preferred Brand 18%18%None
DOXYCYCLINE MONO 100 MG CAPSULE [Monodox]   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 100 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 150 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 50 MG CAPSULE [Monodox]   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 75 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DRIZALMA SPRINKLE DR 20 MG CAPSULE   4 Non-Preferred Drug 41%N/AQ:60
/30Days
DRIZALMA SPRINKLE DR 30 MG CAPSULE   4 Non-Preferred Drug 41%N/AQ:60
/30Days
DRIZALMA SPRINKLE DR 40 MG CAPSULE   4 Non-Preferred Drug 41%N/AQ:90
/30Days
DRIZALMA SPRINKLE DR 60 MG CAPSULE   4 Non-Preferred Drug 41%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 41%N/AP
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 41%N/AP
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 41%N/AP
DROSPIRENONE-EE 3-0.02 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DROSPIRENONE-EE 3-0.03 MG TABLET [Zumandimine]   4 Non-Preferred Drug 41%N/ANone
DROXIA 200MG CAPSULE   3 Preferred Brand 18%18%None
DROXIA 300MG CAPSULE   3 Preferred Brand 18%18%None
DROXIA 400MG CAPSULE   3 Preferred Brand 18%18%None
DROXIDOPA 100 MG CAPSULE [NORTHERA]   4 Non-Preferred Drug 41%N/AP Q:90
/90Days
DROXIDOPA 200 MG CAPSULE [NORTHERA]   4 Non-Preferred Drug 41%N/AP Q:90
/90Days
DROXIDOPA 300 MG CAPSULE [NORTHERA]   4 Non-Preferred Drug 41%N/AP Q:180
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DULOXETINE HCL DR 20 MG CAPSULE [Cymbalta]   3 Preferred Brand 18%18%Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Drizalma]   3 Preferred Brand 18%18%Q:60
/30Days
DULOXETINE HCL DR 40 MG CAPSULE [Irenka]   3 Preferred Brand 18%18%Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Drizalma]   3 Preferred Brand 18%18%Q:60
/30Days
DUPIXENT 100 MG/0.67 ML SYRINGE   5 Specialty Tier 25%N/AP
DUPIXENT 200 MG/1.14 ML PEN INJCTR   5 Specialty Tier 25%N/AP Q:5
/28Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 25%N/AP Q:5
/28Days
DUPIXENT 300 MG/2 ML PEN INJECTOR   5 Specialty Tier 25%N/AP Q:8
/28Days
DUPIXENT 300 MG/2 ML SAFE SYRINGE   5 Specialty Tier 25%N/AP Q:8
/28Days
DUTASTERIDE 0.5 MG CAPSULE [Avodart]   4 Non-Preferred Drug 41%N/AQ:30
/30Days

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.