Q1Medicare.com 2023 Medicare Part D or Medicare Advantage Plan Formulary Browser

2023 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Essential (PDP) (S7126-104-0) Benefit Details Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details.
The Mutual of Omaha Rx Essential (PDP) (S7126-104-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 01 which includes: ME NH
Drugs Starting with Letter B Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter B Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Bacitracin 500 unit/gm Eye Ointment	3	Preferred Brand	20%	20%	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2	Generic	$15.00	$37.50	None
BACLOFEN 10 MG TABLET	2	Generic	$15.00	$37.50	None
BACLOFEN 20 MG TABLET [Lioresal]	2	Generic	$15.00	$37.50	None
BACLOFEN 5 MG TABLET	2	Generic	$15.00	$37.50	None
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal]	4	Non-Preferred Drug	48%	N/A	None
BALVERSA 3 MG TABLET	5	Specialty Tier	25%	N/A	P
BALVERSA 4 MG TABLET	5	Specialty Tier	25%	N/A	P
BALVERSA 5 MG TABLET	5	Specialty Tier	25%	N/A	P
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	3	Preferred Brand	20%	20%	None
BENAZEPRIL HCL 10 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL HCL 20 MG TABLET [Lotensin]	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL HCL 40 MG TABLET [Lotensin]	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL HCL 5 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	None
BENLYSTA 200 MG/ML AUTOINJECT	5	Specialty Tier	25%	N/A	P
BENLYSTA 200 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENZTROPINE MES 0.5 MG TABLET [Cogentin]	3	Preferred Brand	20%	20%	P
BENZTROPINE MES 1 MG TABLET [Cogentin]	3	Preferred Brand	20%	20%	P
BENZTROPINE MES 2 MG TABLET [Cogentin]	3	Preferred Brand	20%	20%	P
BESREMI 500 MCG/ML SYRINGE	5	Specialty Tier	25%	N/A	P
BETAINE 1 GRAM/SCOOP POWDER [Cystadane]	5	Specialty Tier	25%	N/A	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	3	Preferred Brand	20%	20%	None
BETAMETHASONE DP 0.05% LOTION	3	Preferred Brand	20%	20%	None
BETAMETHASONE DP 0.05% OINTMENT [Maxivate]	3	Preferred Brand	20%	20%	None
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak]	2	Generic	$15.00	$37.50	None
BETAMETHASONE DP AUG 0.05% GEL	3	Preferred Brand	20%	20%	None
BETAMETHASONE DP AUG 0.05% LOTION [Diprolene]	4	Non-Preferred Drug	48%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene]	4	Non-Preferred Drug	48%	N/A	None
BETAMETHASONE VA 0.1% CREAM (G) [Valisone]	3	Preferred Brand	20%	20%	None
BETAMETHASONE VALER 0.1% LOTION [Valisone]	3	Preferred Brand	20%	20%	None
BETAMETHASONE VALER 0.1% OINTMENT [Valisone]	3	Preferred Brand	20%	20%	None
BETASERON 0.3 MG KIT	5	Specialty Tier	25%	N/A	P Q:14 /28Days
BETAXOLOL 10 MG TABLET	3	Preferred Brand	20%	20%	None
BETAXOLOL 20 MG TABLET	3	Preferred Brand	20%	20%	None
BETAXOLOL HCL 0.5% EYE DROPS	3	Preferred Brand	20%	20%	None
BETHANECHOL 10 MG TABLET	3	Preferred Brand	20%	20%	None
BETHANECHOL 25 MG TABLET	3	Preferred Brand	20%	20%	None
BETHANECHOL 5 MG TABLET	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETHANECHOL 50 MG TABLET	3	Preferred Brand	20%	20%	None
BEXAROTENE 1% GEL [Targretin]	5	Specialty Tier	25%	N/A	P
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Specialty Tier	25%	N/A	P
BEXSERO PREFILLED SYRINGE	3	Preferred Brand	20%	20%	None
BICALUTAMIDE 50 MG TABLET	2	Generic	$15.00	$37.50	None
BICILL LA PFS 600MU 1ML PED	4	Non-Preferred Drug	48%	N/A	P
BICILLIN LA PFS 1200MU 2ML	4	Non-Preferred Drug	48%	N/A	P
BICILLIN LA. 600000UNIT/ML 1ML	4	Non-Preferred Drug	48%	N/A	P
BIKTARVY 30-120-15 MG TABLET	5	Specialty Tier	25%	N/A	None
BIKTARVY 50-200-25 MG TABLET	5	Specialty Tier	25%	N/A	None
BISOPROLOL FUMARATE 10 MG TABLET	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BISOPROLOL FUMARATE 5 MG TABLET	2	Generic	$15.00	$37.50	None
BISOPROLOL-HCTZ 10-6.25 MG TABLET [Ziac]	2	Generic	$15.00	$37.50	None
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET	2	Generic	$15.00	$37.50	None
BISOPROLOL-HCTZ 5-6.25 MG TABLET	2	Generic	$15.00	$37.50	None
BOOSTRIX TDAP VACCINE SYRINGE	3	Preferred Brand	20%	20%	None
BOOSTRIX TDAP VACCINE VIAL	3	Preferred Brand	20%	20%	None
BOSULIF 100 MG TABLET	5	Specialty Tier	25%	N/A	P Q:90 /30Days
BOSULIF 400 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
BOSULIF 500 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
BRAFTOVI 75 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:180 /30Days
BREO ELLIPTA 100-25 MCG INH	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BREO ELLIPTA 200-25 MCG INH	3	Preferred Brand	20%	20%	None
BREZTRI AEROSPHERE INHALER HFA AER AD	3	Preferred Brand	20%	20%	Q:11 /30Days
BRILINTA 60 MG TABLET	3	Preferred Brand	20%	20%	None
BRILINTA 90mg/1 60 TABLET BOTTLE	3	Preferred Brand	20%	20%	None
BRIMONIDINE 0.2% EYE DROPS [Alphagan]	2	Generic	$15.00	$37.50	None
BRIMONIDINE TARTRATE 0.15% DROPS [Alphagan P]	3	Preferred Brand	20%	20%	None
BRIVIACT 10 MG TABLET	4	Non-Preferred Drug	48%	N/A	Q:60 /30Days
BRIVIACT 10 MG/ML ORAL SOLUTION	4	Non-Preferred Drug	48%	N/A	Q:600 /30Days
BRIVIACT 100 MG TABLET	4	Non-Preferred Drug	48%	N/A	Q:60 /30Days
BRIVIACT 25 MG TABLET	4	Non-Preferred Drug	48%	N/A	Q:60 /30Days
BRIVIACT 50 MG TABLET	4	Non-Preferred Drug	48%	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRIVIACT 75 MG TABLET	4	Non-Preferred Drug	48%	N/A	Q:60 /30Days
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]	4	Non-Preferred Drug	48%	N/A	None
BROMOCRIPTINE 5 MG CAPSULE [Parlodel]	4	Non-Preferred Drug	48%	N/A	None
BRUKINSA 80 MG CAPSULE	5	Specialty Tier	25%	N/A	P
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	48%	N/A	P Q:120 /30Days
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	48%	N/A	P Q:120 /30Days
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	48%	N/A	P Q:60 /30Days
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC]	4	Non-Preferred Drug	48%	N/A	None
BUDESONIDE ER 9 MG TABLET ER [UCERIS]	5	Specialty Tier	25%	N/A	None
BUMETANIDE 0.5 MG TABLET [Bumex]	3	Preferred Brand	20%	20%	None
BUMETANIDE 1 MG TABLET [Bumex]	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUMETANIDE 1 MG/4 ML VIAL	4	Non-Preferred Drug	48%	N/A	None
BUMETANIDE 2 MG TABLET [Bumex]	3	Preferred Brand	20%	20%	None
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone]	3	Preferred Brand	20%	20%	Q:60 /30Days
BUPRENORPHIN-NALOXON 8-2 MG SL SUSLIGUAL TABLET [Suboxone]	2	Generic	$15.00	$37.50	Q:90 /30Days
BUPRENORPHINE 2 MG SUBLIGUAL TABLET [Subutex]	3	Preferred Brand	20%	20%	None
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex]	3	Preferred Brand	20%	20%	None
BUPRENORPHINE-NALOX 2-0.5MG FILM [Suboxone]	3	Preferred Brand	20%	20%	Q:360 /30Days
BUPRENORPHINE-NALOX 4-1MG FILM [Suboxone]	3	Preferred Brand	20%	20%	Q:90 /30Days
BUPRENORPHINE-NALOX 8-2MG FILM [Suboxone]	3	Preferred Brand	20%	20%	Q:90 /30Days
BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone]	2	Generic	$15.00	$37.50	Q:360 /30Days
BUPROPION HCL 100 MG TABLET	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPROPION HCL 75 MG TABLET	2	Generic	$15.00	$37.50	None
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$15.00	$37.50	Q:60 /30Days
BUPROPION HCL SR 150 MG TABLET	2	Generic	$15.00	$37.50	None
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$15.00	$37.50	Q:60 /30Days
BUPROPION HCL SR 200 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$15.00	$37.50	Q:60 /30Days
BUPROPION HCL XL 150 MG TABLET ER 24H [Wellbutrin XL]	2	Generic	$15.00	$37.50	Q:90 /30Days
BUPROPION HCL XL 300 MG TABLET ER 24H [Wellbutrin XL]	2	Generic	$15.00	$37.50	Q:30 /30Days
BUSPIRONE HCL 15 MG TABLET	2	Generic	$15.00	$37.50	None
BUSPIRONE HCL 30 MG TABLET	2	Generic	$15.00	$37.50	None
BUSPIRONE HCL 5 MG TABLET	2	Generic	$15.00	$37.50	None
BUSPIRONE HCL 7.5 MG TABLET	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HYDROCHLORIDE 10 MG TABLET	2	Generic	$15.00	$37.50	None
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS]	4	Non-Preferred Drug	48%	N/A	Q:10 /28Days
BYDUREON BCISE 2 MG AUTOINJECT	3	Preferred Brand	20%	20%	P Q:4 /28Days
BYETTA 10 MCG DOSE PEN INJ	3	Preferred Brand	20%	20%	P Q:2 /30Days
BYETTA 5 MCG DOSE PEN INJ	3	Preferred Brand	20%	20%	P Q:1 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2023 Medicare Part D Mutual of Omaha Rx Essential (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 $505 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 $4,660) 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.
  
  *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. 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 2023)

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.