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Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
Tier 1 (137)
Tier 2 (606)
Tier 3 (655)
Tier 4 (1108)
Tier 5 (492)
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Cick on the first letter of your drug name to browse the formulary:

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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 P

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
PALIPERIDONE ER 1.5 MG TABLET ER 24 [Invega]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
PALIPERIDONE ER 3 MG TABLET ER 24 [Invega]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
PALIPERIDONE ER 6 MG TABLET ER 24 [Invega]   4 Non-Preferred Drug 41%N/AQ:60
/30Days
PALIPERIDONE ER 9 MG TABLET ER 24 [Invega]   4 Non-Preferred Drug 41%N/AQ:30
/30Days
PANRETIN 0.1% GEL   5 Specialty Tier 25%N/ANone
PANTOPRAZOLE SOD DR 20 MG TAB   2 Generic $3.00$9.00Q:30
/30Days
PANTOPRAZOLE SOD DR 40 MG TABLET DR [Protonix]   2 Generic $3.00$9.00Q:60
/30Days
PARICALCITOL 1 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 41%N/ANone
PARICALCITOL 2 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 41%N/ANone
PARICALCITOL 4 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PAROMOMYCIN 250 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
PAROXETINE HCL 10 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
PAROXETINE HCL 10 MG/5 ML ORAL SUSPENSION [Paxil]   4 Non-Preferred Drug 41%N/AQ:900
/30Days
PAROXETINE HCL 20 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
PAROXETINE HCL 30 MG TABLET   2 Generic $3.00$9.00Q:60
/30Days
PAROXETINE HCL 40 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
PASER GRANULES 4GM PACKET   4 Non-Preferred Drug 41%N/ANone
PAXIL ORAL SUSPENSION 10 MG/5ML   4 Non-Preferred Drug 41%N/AQ:900
/30Days
PEDVAXHIB VACCINE VIAL   3 Preferred Brand 18%18%None
PEG 3350-ELECTROLYTE SOLUTION RECON [TriLyte]   2 Generic $3.00$9.00None
PEG-3350 AND ELECTROLYTES SOLUTION SOLUTION RECON   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS   5 Specialty Tier 25%N/AP Q:2
/28Days
PEGASYS INJECTION   5 Specialty Tier 25%N/AP Q:4
/28Days
PEMAZYRE 13.5 MG TABLET   5 Specialty Tier 25%N/AP
PEMAZYRE 4.5 MG TABLET   5 Specialty Tier 25%N/AP
PEMAZYRE 9 MG TABLET   5 Specialty Tier 25%N/AP
PENICILLAMINE 250 MG TABLET [Depen]   5 Specialty Tier 25%N/AP
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   2 Generic $3.00$9.00P
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   4 Non-Preferred Drug 41%N/AP
PENICILLIN GK 20 MILLION UNIT   4 Non-Preferred Drug 41%N/AP
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   2 Generic $3.00$9.00None
PENICILLIN VK 125 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
PENICILLIN VK 250 MG TABLET   2 Generic $3.00$9.00None
PENICILLIN VK 500 MG TABLET [Veetids]   2 Generic $3.00$9.00None
PENTACEL VIAL KIT   3 Preferred Brand 18%18%None
PENTAMIDINE 300 MG INHAL POWDER VIAL-NEB [NebuPent]   3 Preferred Brand 18%18%P Q:1
/28Days
PENTAMIDINE 300 MG VIAL [Pentam]   3 Preferred Brand 18%18%None
PENTASA 250MG CAPSULE SA   4 Non-Preferred Drug 41%N/ANone
PENTASA 500MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
PENTOXIFYLLINE 400MG TABLET SA   2 Generic $3.00$9.00None
PERIOGARD 0.12% ORAL RINSE MOUTHWASH [Perisol]   2 Generic $3.00$9.00None
PERMETHRIN 5% CREAM (G) [Elimite]   3 Preferred Brand 18%18%None
PERPHENAZINE 16 MG TABLET [Trilafon]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PERPHENAZINE 2 MG TABLET [Trilafon]   4 Non-Preferred Drug 41%N/ANone
PERPHENAZINE 4 MG TABLET [Trilafon]   4 Non-Preferred Drug 41%N/ANone
PERPHENAZINE 8 MG TABLET [Trilafon]   4 Non-Preferred Drug 41%N/ANone
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT   4 Non-Preferred Drug 41%N/AQ:1
/28Days
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT   4 Non-Preferred Drug 41%N/AQ:1
/28Days
PHENELZINE SULFATE 15 MG TABLET [Nardil]   3 Preferred Brand 18%18%None
Phenobarbital 100mg/1   3 Preferred Brand 18%18%P Q:120
/30Days
PHENOBARBITAL 15 MG TABLET   3 Preferred Brand 18%18%P Q:120
/30Days
PHENOBARBITAL 16.2 MG TABLET   3 Preferred Brand 18%18%P Q:120
/30Days
PHENOBARBITAL 20 MG/5 ML ELIX ELIXIR   4 Non-Preferred Drug 41%N/AP Q:1500
/30Days
PHENOBARBITAL 30 MG TABLET   3 Preferred Brand 18%18%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHENOBARBITAL 32.4 MG TABLET   3 Preferred Brand 18%18%P Q:120
/30Days
Phenobarbital 60mg/1   3 Preferred Brand 18%18%P Q:120
/30Days
PHENOBARBITAL 64.8 MG TABLET   3 Preferred Brand 18%18%P Q:120
/30Days
PHENOBARBITAL 97.2 MG TABLET   3 Preferred Brand 18%18%P Q:120
/30Days
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [Dilantin]   2 Generic $3.00$9.00None
PHENYTOIN 50 MG CHEWABLE TABLET [Dilantin]   2 Generic $3.00$9.00None
PHENYTOIN SOD EXT 100 MG CAP   2 Generic $3.00$9.00None
PHENYTOIN SOD EXT 200 MG CAP   2 Generic $3.00$9.00None
PHENYTOIN SOD EXT 300 MG CAPSULE [Phenytek]   2 Generic $3.00$9.00None
PIFELTRO 100 MG TABLET   4 Non-Preferred Drug 41%N/ANone
PILOCARPINE 1% EYE DROPS [Pilocar]   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PILOCARPINE 2% EYE DROPS [Pilocar]   3 Preferred Brand 18%18%None
PILOCARPINE 4% EYE DROPS [Pilocar]   3 Preferred Brand 18%18%None
PILOCARPINE HCL 5 MG TABLET [Salagen]   4 Non-Preferred Drug 41%N/ANone
PILOCARPINE HCL 7.5 MG TABLET [Salagen]   4 Non-Preferred Drug 41%N/ANone
PIMOZIDE 1 MG TABLET [Orap]   4 Non-Preferred Drug 41%N/ANone
PIMOZIDE 2 MG TABLET [Orap]   4 Non-Preferred Drug 41%N/ANone
PINDOLOL 10 MG TABLET [Visken]   4 Non-Preferred Drug 41%N/ANone
PINDOLOL 5 MG TABLET [Visken]   4 Non-Preferred Drug 41%N/ANone
PIOGLITAZONE HCL 15 MG TABLET [Actos]   2 Generic $3.00$9.00Q:30
/30Days
PIOGLITAZONE HCL 30 MG TABLET [Actos]   2 Generic $3.00$9.00Q:30
/30Days
PIOGLITAZONE HCL 45 MG TABLET [Actos]   2 Generic $3.00$9.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PIPERACIL-TAZOBACT 2.25 GM VIAL [Zosyn]   4 Non-Preferred Drug 41%N/ANone
PIPERACIL-TAZOBACT 3.375 GM VIAL [Zosyn]   4 Non-Preferred Drug 41%N/ANone
PIPERACIL-TAZOBACT 4.5 GM VIAL [Zosyn]   4 Non-Preferred Drug 41%N/ANone
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn]   4 Non-Preferred Drug 41%N/ANone
PIQRAY 200 MG DAILY DOSE TABLET   5 Specialty Tier 25%N/AP
PIQRAY 250 MG DAILY DOSE TABLET   5 Specialty Tier 25%N/AP
PIQRAY 300 MG DAILY DOSE TABLET   5 Specialty Tier 25%N/AP
PIRFENIDONE 267 MG TABLET [ESBRIET]   5 Specialty Tier 25%N/AP Q:270
/30Days
PIRFENIDONE 801 MG TABLET [ESBRIET]   5 Specialty Tier 25%N/AP Q:90
/30Days
PLENAMINE 15% SOLUTION IV SOLUTION   4 Non-Preferred Drug 41%N/AP
PODOFILOX 0.5% TOPICAL SOLUTION [Condylox]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POLYMYXIN B-TMP EYE DROPS   2 Generic $3.00$9.00None
POMALYST 1 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
POMALYST 2 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
POMALYST 3 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
POMALYST 4 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
POSACONAZOLE DR 100 MG TABLET [Noxafil]   5 Specialty Tier 25%N/AP Q:96
/30Days
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG   4 Non-Preferred Drug 41%N/ANone
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CITRATE ER 10 MEQ TB   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CITRATE ER 15 MEQ TABLET   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CITRATE ER 5 MEQ TAB   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CL 10 MEQ/100 ML SOL PIGGYBACK   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 10% (20 MEQ/15ML) LIQUID [Kay Ciel]   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 20 MEQ PACKET [Klor-Con]   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 20 MEQ-0.45% NACL IV SOLUTION   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 20 MEQ/100 ML SOL PIGGYBACK   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 20% (40 MEQ/15ML) LIQUID [Kaon-CL]   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 40 MEQ/100 ML SOL PIGGYBACK   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 40 MEQ/20 ML CONC VIAL [PROAMP]   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL 60 MEQ/30 ML CONC VIAL [PROAMP]   4 Non-Preferred Drug 41%N/ANone
POTASSIUM CL ER 10 MEQ CAPSULE ER [Micro-K Extencaps]   2 Generic $3.00$9.00None
POTASSIUM CL ER 10 MEQ TABLET [Klotrix]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CL ER 10 MEQ TABLET ER PRT [Klotrix]   2 Generic $3.00$9.00None
POTASSIUM CL ER 15 MEQ TABLET ER PRT [Klor-Con M15]   2 Generic $3.00$9.00None
Potassium cl er 20 meq tablet   2 Generic $3.00$9.00None
POTASSIUM CL ER 20 MEQ TABLET ER PRT [Klor-Con M20]   2 Generic $3.00$9.00None
POTASSIUM CL ER 8 MEQ CAPSULE ER [Micro-K Extencaps]   2 Generic $3.00$9.00None
POTASSIUM CL ER 8 MEQ TABLET [Slow-K]   2 Generic $3.00$9.00None
PRAMIPEXOLE 0.125 MG TABLET [Mirapex]   2 Generic $3.00$9.00None
PRAMIPEXOLE 0.25 MG TABLET [Mirapex]   2 Generic $3.00$9.00None
PRAMIPEXOLE 0.5 MG TABLET   2 Generic $3.00$9.00None
PRAMIPEXOLE 0.75 MG TABLET   2 Generic $3.00$9.00None
PRAMIPEXOLE 1 MG TABLET [Mirapex]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAMIPEXOLE 1.5 MG TABLET [Mirapex]   2 Generic $3.00$9.00None
PRASUGREL 10 MG TABLET [Effient]   4 Non-Preferred Drug 41%N/ANone
PRASUGREL 5 MG TABLET [Effient]   4 Non-Preferred Drug 41%N/ANone
PRAVASTATIN SODIUM 10 MG TABLET [Pravachol]   1 Preferred Generic $1.00$3.00Q:30
/30Days
PRAVASTATIN SODIUM 20 MG TAB   1 Preferred Generic $1.00$3.00Q:30
/30Days
PRAVASTATIN SODIUM 40 MG TABLET [Pravachol]   1 Preferred Generic $1.00$3.00Q:30
/30Days
PRAVASTATIN SODIUM 80 MG TABLET [Pravachol]   1 Preferred Generic $1.00$3.00Q:30
/30Days
PRAZIQUANTEL 600 MG TABLET [Biltricide]   4 Non-Preferred Drug 41%N/ANone
PRAZOSIN 1 MG CAPSULE [Minipress]   2 Generic $3.00$9.00None
PRAZOSIN 2 MG CAPSULE [Minipress]   2 Generic $3.00$9.00None
PRAZOSIN 5 MG CAPSULE [Minipress]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNICARBATE 0.1% OINTMENT [Dermatop]   4 Non-Preferred Drug 41%N/ANone
PREDNISOLONE 15 MG/5 ML SOLUTION   2 Generic $3.00$9.00None
PREDNISOLONE 5 MG/5 ML SOLUTION [Pediapred]   4 Non-Preferred Drug 41%N/ANone
PREDNISOLONE AC 1% EYE DROP   3 Preferred Brand 18%18%None
PREDNISOLONE SOD 1% EYE DROP   4 Non-Preferred Drug 41%N/ANone
PREDNISOLONE SOD PH 25 MG/5 ML SOLUTION   3 Preferred Brand 18%18%None
PREDNISONE 1 MG TABLET   2 Generic $3.00$9.00None
PREDNISONE 10 MG TABLET [Sterapred DS]   2 Generic $3.00$9.00None
PREDNISONE 10 MG TABLET DOSE PACK   2 Generic $3.00$9.00None
PREDNISONE 10 MG TABLET DOSE PACK   2 Generic $3.00$9.00None
PREDNISONE 2.5 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
PREDNISONE 20 MG TABLET [Predone]   2 Generic $3.00$9.00None
PREDNISONE 5 MG TABLET   2 Generic $3.00$9.00None
PREDNISONE 5 MG TABLET   2 Generic $3.00$9.00None
PREDNISONE 5 MG TABLET [Sterapred]   2 Generic $3.00$9.00None
PREDNISONE 5 MG/5 ML SOLUTION   4 Non-Preferred Drug 41%N/ANone
PREDNISONE 50MG TABLET   2 Generic $3.00$9.00None
PREDNISONE 5MG/ML SOLUTION   4 Non-Preferred Drug 41%N/ANone
PREGABALIN 100 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:90
/30Days
PREGABALIN 150 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:90
/30Days
PREGABALIN 20 MG/ML SOLUTION [Lyrica]   3 Preferred Brand 18%18%Q:900
/30Days
PREGABALIN 200 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREGABALIN 225 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:60
/30Days
PREGABALIN 25 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:90
/30Days
PREGABALIN 300 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:60
/30Days
PREGABALIN 50 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:90
/30Days
PREGABALIN 75 MG CAPSULE [Lyrica]   3 Preferred Brand 18%18%Q:90
/30Days
PREHEVBRIO 10 MCG/ML VIAL   3 Preferred Brand 18%18%P
PREMARIN 0.3 MG TABLET   3 Preferred Brand 18%18%None
PREMARIN 0.45MG TABLET   3 Preferred Brand 18%18%None
PREMARIN 0.625 MG TABLET   3 Preferred Brand 18%18%None
Premarin 0.625mg/g   3 Preferred Brand 18%18%None
PREMARIN 0.9MG TABLET   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREMARIN 1.25 MG TABLET   3 Preferred Brand 18%18%None
PREMASOL 10% IV SOLUTION   2 Generic $3.00$9.00P
PREMPHASE 0.625-5 MG TABLET   3 Preferred Brand 18%18%None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   3 Preferred Brand 18%18%None
PREMPRO 0.45-1.5 MG TABLET 28 EA   3 Preferred Brand 18%18%None
PREMPRO 0.625-5 MG TABLET   3 Preferred Brand 18%18%None
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK   3 Preferred Brand 18%18%None
PREVALITE PACKET   3 Preferred Brand 18%18%None
PREVYMIS 240 MG   4 Non-Preferred Drug 41%N/AQ:30
/30Days
PREVYMIS 480 MG   4 Non-Preferred Drug 41%N/AQ:30
/30Days
PREZCOBIX 800 MG-150 MG TABLET   4 Non-Preferred Drug 41%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREZISTA 100 MG/ML SUSPENSION   5 Specialty Tier 25%N/AQ:360
/30Days
PREZISTA 150MG TABLETS   3 Preferred Brand 18%18%Q:240
/30Days
PREZISTA 800 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
PREZISTA TABLET 600MG   5 Specialty Tier 25%N/AQ:60
/30Days
PREZISTA TABLET 75MG   3 Preferred Brand 18%18%Q:480
/30Days
PRIFTIN 150 MG TABLET   4 Non-Preferred Drug 41%N/ANone
PRIMAQUINE 26.3 MG TABLET [Primaquine]   3 Preferred Brand 18%18%None
PRIMIDONE 250 MG TABLET [Mysoline]   2 Generic $3.00$9.00None
PRIMIDONE 50 MG TABLET [Mysoline]   2 Generic $3.00$9.00None
PRIVIGEN 10% VIAL   5 Specialty Tier 25%N/AP
PROBENECID 500 MG TABLET   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROBENECID-COLCHICINE TABLET   3 Preferred Brand 18%18%None
PROCHLORPERAZINE 10 MG TAB   2 Generic $3.00$9.00None
PROCHLORPERAZINE 5 MG TABLET   2 Generic $3.00$9.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Drug 41%N/ANone
PROCRIT 10000U/ML VIAL   3 Preferred Brand 18%18%P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   3 Preferred Brand 18%18%P
PROCRIT 3,000 UNITS/ML VIAL   3 Preferred Brand 18%18%P
PROCRIT 4,000 UNITS/ML VIAL   3 Preferred Brand 18%18%P
PROCRIT 40000U/ML VIAL PR   5 Specialty Tier 25%N/AP
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   5 Specialty Tier 25%N/AP
PROCTO-MED HC 2.5% CREAM CRM/PE APP [Proctozone-HC]   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
procto-pak 1% cream   2 Generic $3.00$9.00None
PROCTOSOL-HC 2.5% CREAM   2 Generic $3.00$9.00None
PROCTOZONE-HC 2.5% CREAM   2 Generic $3.00$9.00None
PROGRAF 0.2 MG GRANULE PACKET   3 Preferred Brand 18%18%P
PROGRAF 1 MG GRANULE PACKET   3 Preferred Brand 18%18%P
PROLASTIN C 1,000 MG VIAL   5 Specialty Tier 25%N/AP
PROLIA 60MG/ML INJECTION   4 Non-Preferred Drug 41%N/AP Q:1
/180Days
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK   5 Specialty Tier 25%N/AP Q:180
/30Days
PROMACTA 12.5 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
PROMACTA 25 MG SUSPENSION POWDER PACK   5 Specialty Tier 25%N/AP Q:180
/30Days
PROMACTA 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
PROMACTA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
PROMACTA 75 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
PROPAFENONE HCL 150 MG TABLET [Rythmol]   2 Generic $3.00$9.00None
PROPAFENONE HCL 225MG TABLET   2 Generic $3.00$9.00None
PROPAFENONE HCL 300 MG TABLET [Rythmol]   4 Non-Preferred Drug 41%N/ANone
PROPAFENONE HCL ER 225 MG CAP   4 Non-Preferred Drug 41%N/ANone
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Drug 41%N/ANone
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Drug 41%N/ANone
PROPRANOLOL 10 MG TABLET   2 Generic $3.00$9.00None
PROPRANOLOL 20 MG TABLET [Inderal]   2 Generic $3.00$9.00None
PROPRANOLOL 20MG/5ML TUBEX   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL 40 MG TABLET [Inderal]   2 Generic $3.00$9.00None
PROPRANOLOL 40MG/5ML TUBEX   2 Generic $3.00$9.00None
PROPRANOLOL 60 MG TABLET   2 Generic $3.00$9.00None
PROPRANOLOL 80 MG TABLET [Inderal]   2 Generic $3.00$9.00None
PROPRANOLOL ER 120 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
PROPRANOLOL ER 160 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
PROPRANOLOL ER 60 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
PROPRANOLOL ER 80 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
PROPYLTHIOURACIL 50 MG TABLET   3 Preferred Brand 18%18%None
PROQUAD VIAL   3 Preferred Brand 18%18%None
PROTRIPTYLINE HCL 10 MG TABLET [Vivactil]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROTRIPTYLINE HCL 5 MG TABLET [Vivactil]   4 Non-Preferred Drug 41%N/ANone
PULMOZYME 1MG/ML AMPUL   5 Specialty Tier 25%N/AP Q:150
/30Days
PURIXAN 20 MG/ML ORAL SUSPENSION   5 Specialty Tier 25%N/ANone
PYRAZINAMIDE 500 MG TABLET   4 Non-Preferred Drug 41%N/ANone
PYRIDOSTIGMINE 60 MG/5 ML SOLUTION SYRUP [Mestinon]   4 Non-Preferred Drug 41%N/ANone
PYRIDOSTIGMINE BR 60 MG TABLET   3 Preferred Brand 18%18%None
PYRIDOSTIGMINE BR ER 180 MG TAB   4 Non-Preferred Drug 41%N/ANone
PYRIMETHAMINE 25 MG TABLET [Daraprim]   5 Specialty Tier 25%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.