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2024 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Mutual of Omaha Rx Premier (PDP) (S7126-073-0)
Tier 1 (230)
Tier 2 (578)
Tier 3 (658)
Tier 4 (1110)
Tier 5 (543)
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Uses Step Therapy:
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2024 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Premier (PDP) (S7126-073-0)
Benefits & Contact Info           
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 Premier (PDP) (S7126-073-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 4 which includes: NJ
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET [Dostinex]   4 Non-Preferred Drug 42%N/ANone
CABLIVI 11 MG KIT   5 Specialty Tier 28%N/AP
CABOMETYX 20 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM (G) [Dovonex]   4 Non-Preferred Drug 42%N/AQ:120
/30Days
CALCIPOTRIENE 0.005% OINTMENT [Dovonex]   4 Non-Preferred Drug 42%N/AQ:120
/30Days
CALCIPOTRIENE 0.005% SOLUTION [Dovonex Scalp]   3 Preferred Brand $47.00$117.50Q:120
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $47.00$117.50None
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2* Generic $10.00$25.00None
CALCITRIOL 1 MCG/ML SOLUTION ORAL   4 Non-Preferred Drug 42%N/ANone
CALCIUM ACETATE 667 MG CAPSULE [PhosLo]   3 Preferred Brand $47.00$117.50None
CALCIUM ACETATE 667 MG TABLET [PhosLo]   3 Preferred Brand $47.00$117.50None
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 28%N/AP Q:60
/30Days
CALQUENCE 100 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
CAMRESE LO TABLET   4 Non-Preferred Drug 42%N/ANone
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   2* Generic $10.00$25.00Q:60
/30Days
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   2* Generic $10.00$25.00Q:30
/30Days
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   2* Generic $10.00$25.00Q:60
/30Days
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   2* Generic $10.00$25.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANDESARTAN-HCTZ 16-12.5 MG TABLET [Atacand HCT]   4 Non-Preferred Drug 42%N/AQ:60
/30Days
CANDESARTAN-HCTZ 32-12.5 MG TABLET [Atacand HCT]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
CANDESARTAN-HCTZ 32-25 MG TABLET [Atacand HCT]   4 Non-Preferred Drug 42%N/AQ:30
/30Days
CAPLYTA 10.5 MG CAPSULE   4 Non-Preferred Drug 42%N/AQ:30
/30Days
CAPLYTA 21 MG CAPSULE   4 Non-Preferred Drug 42%N/AQ:30
/30Days
CAPLYTA 42 MG CAPSULE   4 Non-Preferred Drug 42%N/AQ:30
/30Days
CAPRELSA 100 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
CAPRELSA 300 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
CAPTOPRIL 12.5 MG TABLET [Capoten]   2* Generic $10.00$25.00None
CAPTOPRIL 25 MG TABLET   2* Generic $10.00$25.00None
CARBAMAZEPINE 100 MG TABLET CHEW   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Drug 42%N/ANone
CARBAMAZEPINE 200 MG TABLET [Tegretol]   3 Preferred Brand $47.00$117.50None
CARBAMAZEPINE ER 100 MG CAPSULE CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 42%N/ANone
CARBAMAZEPINE ER 100 MG TABLET 12H [Tegretol -XR]   4 Non-Preferred Drug 42%N/ANone
CARBAMAZEPINE ER 200 MG CAPSULE CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 42%N/ANone
CARBAMAZEPINE ER 200 MG TABLET 12H [Tegretol -XR]   4 Non-Preferred Drug 42%N/ANone
CARBAMAZEPINE ER 300 MG CAPSULE CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 42%N/ANone
CARBAMAZEPINE ER 400 MG TABLET 12H [Tegretol -XR]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA 25 MG TABLET [Lodosyn]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVO 10-100 MG ODT TABLET RAPDIS [Parcopa]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVO 25-100 MG ODT TABLET RAPDIS [Parcopa]   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVO 25-250 MG ODT TABLET RAPDIS [Parcopa]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVO ER 25-100 TABLET [SINEMET CR]   3 Preferred Brand $47.00$117.50None
CARBIDOPA-LEVO ER 50-200 TABLET [SINEMET CR]   3 Preferred Brand $47.00$117.50None
CARBIDOPA-LEVODOPA 10-100 TABLET [SINEMET]   2* Generic $10.00$25.00None
CARBIDOPA-LEVODOPA 100 MG-ENTA TABLET [Stalevo]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVODOPA 125 MG-ENTA TABLET [Stalevo]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVODOPA 150 MG-ENTA TABLET [Stalevo]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVODOPA 200 MG-ENTA TABLET [Stalevo]   4 Non-Preferred Drug 42%N/ANone
CARBIDOPA-LEVODOPA 25-100 TABLET [SINEMET]   2* Generic $10.00$25.00None
CARBIDOPA-LEVODOPA 25-250 TABLET [SINEMET]   2* Generic $10.00$25.00None
CARBIDOPA-LEVODOPA 50 MG-ENTA TABLET [Stalevo]   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 75 MG-ENTA TABLET [Stalevo]   4 Non-Preferred Drug 42%N/ANone
CARGLUMIC ACID 200 MG TABLET SUSP TABLET DISPER [Carbaglu]   5 Specialty Tier 28%N/AP
CARTEOLOL HCL 1% EYE DROPS   2* Generic $10.00$25.00None
CARTIA XT 120MG CAPSULE SA   2* Generic $10.00$25.00None
CARTIA XT 180 MG CAPSULE ER 24H [Tiazac]   2* Generic $10.00$25.00None
CARTIA XT 240MG CAPSULE SA   2* Generic $10.00$25.00None
CARTIA XT 300 MG CAPSULE   2* Generic $10.00$25.00None
CARVEDILOL 12.5 MG TABLET [Coreg]   1* Preferred Generic $1.00$2.50None
CARVEDILOL 25 MG TABLET [Coreg]   1* Preferred Generic $1.00$2.50None
CARVEDILOL 3.125 MG TABLET [Coreg]   1* Preferred Generic $1.00$2.50None
CARVEDILOL 6.25 MG TABLET [Coreg]   1* Preferred Generic $1.00$2.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CASPOFUNGIN ACETATE 50 MG VIAL [Cancidas]   4 Non-Preferred Drug 42%N/ANone
CASPOFUNGIN ACETATE 70 MG VIAL [Cancidas]   4 Non-Preferred Drug 42%N/ANone
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 28%N/AP Q:84
/56Days
CEFACLOR 250 MG CAPSULE [Ceclor]   3 Preferred Brand $47.00$117.50None
CEFACLOR 500 MG CAPSULE [Ceclor]   3 Preferred Brand $47.00$117.50None
CEFAZOLIN 1 GM VIAL [Kefzol]   4 Non-Preferred Drug 42%N/ANone
CEFAZOLIN 10 GM VIAL [Kefzol]   4 Non-Preferred Drug 42%N/ANone
CEFAZOLIN 500 MG VIAL [Ancef]   4 Non-Preferred Drug 42%N/ANone
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [Omnicef]   3 Preferred Brand $47.00$117.50None
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [Omnicef]   3 Preferred Brand $47.00$117.50None
CEFDINIR 300 MG CAPSULE   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFEPIME HCL 1 GM VIAL [Maxipime]   4 Non-Preferred Drug 42%N/ANone
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   4 Non-Preferred Drug 42%N/ANone
CEFIXIME 100 MG/5 ML SUSPENSION [Suprax]   4 Non-Preferred Drug 42%N/ANone
CEFIXIME 200 MG/5 ML SUSPENSION [Suprax]   4 Non-Preferred Drug 42%N/ANone
CEFIXIME 400 MG CAPSULE [Suprax]   4 Non-Preferred Drug 42%N/ANone
CEFOXITIN 1 GM VIAL [Mefoxin]   4 Non-Preferred Drug 42%N/AP
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 42%N/AP
CEFOXITIN 2 GM VIAL [Mefoxin]   4 Non-Preferred Drug 42%N/AP
CEFPODOXIME 100 MG TABLET [Vantin]   4 Non-Preferred Drug 42%N/ANone
CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [Vantin]   4 Non-Preferred Drug 42%N/ANone
CEFPODOXIME 200 MG 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
CEFPODOXIME 50 MG/5 ML SUSPENSION   4 Non-Preferred Drug 42%N/ANone
CEFTAZIDIME 1 GM VIAL [Tazidime]   4 Non-Preferred Drug 42%N/AP
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 42%N/AP
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 42%N/AP
CEFTRIAXONE 1 GM VIAL [Rocephin]   4 Non-Preferred Drug 42%N/ANone
CEFTRIAXONE 10 GM VIAL [Rocephin]   4 Non-Preferred Drug 42%N/ANone
CEFTRIAXONE 2 GM VIAL [Rocephin]   4 Non-Preferred Drug 42%N/ANone
CEFTRIAXONE 250 MG VIAL [Rocephin]   4 Non-Preferred Drug 42%N/ANone
CEFTRIAXONE 500 MG VIAL [Rocephin]   4 Non-Preferred Drug 42%N/ANone
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 42%N/AP
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 42%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME AXETIL 250 MG TABLET [Ceftin]   3 Preferred Brand $47.00$117.50None
CEFUROXIME AXETIL 500 MG TABLET [Ceftin]   3 Preferred Brand $47.00$117.50None
CELECOXIB 100 MG CAPSULE [Celebrex]   3 Preferred Brand $47.00$117.50None
CELECOXIB 200 MG CAPSULE [Celebrex]   3 Preferred Brand $47.00$117.50None
CELECOXIB 400 MG CAPSULE [Celebrex]   3 Preferred Brand $47.00$117.50None
CELECOXIB 50 MG CAPSULE [Celebrex]   3 Preferred Brand $47.00$117.50None
CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION [Keflex]   2* Generic $10.00$25.00None
CEPHALEXIN 250 MG CAPSULE   2* Generic $10.00$25.00None
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [Keflex]   2* Generic $10.00$25.00None
CEPHALEXIN 500 MG CAPSULE   2* Generic $10.00$25.00None
CETIRIZINE HCL 1 MG/ML SOLUTION [Zyrtec Syrup]   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORHEXIDINE GLUCONATE 0.12% RINSE   2* Generic $10.00$25.00None
CHLOROQUINE PH 250 MG TABLET   4 Non-Preferred Drug 42%N/ANone
CHLOROQUINE PH 500 MG TABLET   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 100 MG TABLET [Thorazine]   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 100 MG/ML ORAL CONC   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 200 MG TABLET [Thorazine]   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 30 MG/ML ORAL CONC   4 Non-Preferred Drug 42%N/ANone
CHLORPROMAZINE 50 MG TABLET [Thorazine]   4 Non-Preferred Drug 42%N/ANone
CHLORTHALIDONE 25 MG TABLET   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORTHALIDONE 50 MG TABLET   2* Generic $10.00$25.00None
CHOLBAM 250 MG CAPSULE   5 Specialty Tier 28%N/AP
CHOLBAM 50 MG CAPSULE   5 Specialty Tier 28%N/AP Q:120
/30Days
CHOLESTYRAMINE LIGHT POWDER PACKET [Questran Light]   3 Preferred Brand $47.00$117.50None
CHOLESTYRAMINE PACKET   3 Preferred Brand $47.00$117.50None
CICLOPIROX 0.77% CREAM (G) [Loprox]   2* Generic $10.00$25.00Q:90
/28Days
CICLOPIROX 0.77% GEL   3 Preferred Brand $47.00$117.50Q:100
/28Days
CICLOPIROX 0.77% TOPICAL SUSPENSION   3 Preferred Brand $47.00$117.50Q:60
/28Days
CICLOPIROX 1% SHAMPOO [Loprox]   3 Preferred Brand $47.00$117.50Q:120
/28Days
CICLOPIROX 8% SOLUTION [Penlac]   2* Generic $10.00$25.00Q:6.6
/28Days
Cilastatin 250 MG / Imipenem 250 MG Injection   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cilastatin 500 MG / Imipenem 500 MG Injection   4 Non-Preferred Drug 42%N/ANone
CILOSTAZOL 100 MG TABLET   2* Generic $10.00$25.00None
CILOSTAZOL 50 MG TABLET   2* Generic $10.00$25.00None
CIMDUO 300-300 MG TABLET   4 Non-Preferred Drug 42%N/ANone
CINACALCET HCL 30 MG TABLET [Sensipar]   4 Non-Preferred Drug 42%N/AP
CINACALCET HCL 60 MG TABLET [Sensipar]   4 Non-Preferred Drug 42%N/AP
CINACALCET HCL 90 MG TABLET [Sensipar]   4 Non-Preferred Drug 42%N/AP
CINRYZE 500 UNIT VIAL-DILUENT   5 Specialty Tier 28%N/AP
CIPROFLOX-DEXAMETH OTIC SUSPENSION EYE DROPPER [Ciprodex Otic]   4 Non-Preferred Drug 42%N/AQ:7.5
/7Days
CIPROFLOXACIN 0.2% OTIC SOLUTION DROPERETTE [Cetraxal]   4 Non-Preferred Drug 42%N/ANone
CIPROFLOXACIN 0.3% EYE DROPS [Ciloxan]   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN 200 MG/100ML-D5W PIGGYBACK [Cipro]   4 Non-Preferred Drug 42%N/AP
CIPROFLOXACIN HCL 250 MG TABLET [Cipro]   2* Generic $10.00$25.00None
CIPROFLOXACIN HCL 500 MG TABLET [Cipro]   2* Generic $10.00$25.00None
CIPROFLOXACIN HCL 750 MG TABLET [Cipro]   2* Generic $10.00$25.00None
CITALOPRAM HBR 10 MG TABLET [Celexa]   1* Preferred Generic $1.00$2.50Q:30
/30Days
CITALOPRAM HBR 10 MG/5 ML SOLUTION [Celexa]   3 Preferred Brand $47.00$117.50None
CITALOPRAM HBR 20 MG TABLET [Celexa]   1* Preferred Generic $1.00$2.50Q:30
/30Days
CITALOPRAM HBR 40 MG TABLET   1* Preferred Generic $1.00$2.50Q:30
/30Days
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 42%N/ANone
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 42%N/ANone
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 42%N/ANone
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Drug 42%N/ANone
CLARITHROMYCIN 250 MG TABLET   4 Non-Preferred Drug 42%N/ANone
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Drug 42%N/ANone
CLARITHROMYCIN 500 MG TABLET [Biaxin]   4 Non-Preferred Drug 42%N/ANone
CLARITHROMYCIN ER 500 MG TABLET ER 24H [Biaxin XL]   4 Non-Preferred Drug 42%N/ANone
CLINDAMYCIN 2% VAGINAL CREAM w/APPL [Clindesse]   4 Non-Preferred Drug 42%N/ANone
CLINDAMYCIN HCL 150 MG CAPSULE [Cleocin]   2* Generic $10.00$25.00None
CLINDAMYCIN HCL 300 MG CAPSULE [Cleocin]   2* Generic $10.00$25.00None
CLINDAMYCIN HCL 75 MG CAPSULE [Cleocin]   2* Generic $10.00$25.00None
CLINDAMYCIN PH 1% SOLUTION   3 Preferred Brand $47.00$117.50Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PH 900 MG/6 ML VIAL [Cleocin]   4 Non-Preferred Drug 42%N/AP
CLINDAMYCIN PHOSP 1% LOTION [ClindaMax]   3 Preferred Brand $47.00$117.50Q:120
/30Days
CLINDAMYCIN PHOSPHATE 1% GEL [ClindaMax]   3 Preferred Brand $47.00$117.50Q:120
/30Days
CLINDAMYCIN PHOSPHATE 1% GEL DAILY [ClindaMax]   3 Preferred Brand $47.00$117.50Q:150
/30Days
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2* Generic $10.00$25.00None
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 42%N/AP
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 42%N/AP
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 42%N/AP
CLOBAZAM 10 MG TABLET [ONFI]   4 Non-Preferred Drug 42%N/AP Q:60
/30Days
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION [ONFI]   4 Non-Preferred Drug 42%N/AP Q:480
/30Days
CLOBAZAM 20 MG TABLET [ONFI]   4 Non-Preferred Drug 42%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL 0.05% CREAM (g) [Temovate]   4 Non-Preferred Drug 42%N/AQ:120
/28Days
CLOBETASOL 0.05% GEL [Temovate]   4 Non-Preferred Drug 42%N/AQ:120
/28Days
CLOBETASOL 0.05% OINTMENT [Temovate E]   4 Non-Preferred Drug 42%N/AQ:120
/28Days
CLOBETASOL 0.05% SOLUTION [Temovate Scalp]   4 Non-Preferred Drug 42%N/AQ:100
/28Days
CLOBETASOL 0.05% TOPICAL LOTION [Clobex]   4 Non-Preferred Drug 42%N/AQ:118
/28Days
CLOBETASOL EMOLLIENT 0.05% CREAM (G) [Temovate E]   4 Non-Preferred Drug 42%N/AQ:120
/28Days
CLOBETASOL PROP 0.05% FOAM [Olux]   4 Non-Preferred Drug 42%N/AQ:100
/28Days
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   4 Non-Preferred Drug 42%N/AQ:236
/28Days
CLOMIPRAMINE 25 MG CAPSULE [Anafranil]   4 Non-Preferred Drug 42%N/ANone
CLOMIPRAMINE 50 MG CAPSULE [Anafranil]   4 Non-Preferred Drug 42%N/ANone
CLOMIPRAMINE 75 MG CAPSULE [Anafranil]   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 0.125 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 42%N/AQ:90
/30Days
CLONAZEPAM 0.25 MG ODT TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 42%N/AQ:90
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 42%N/AQ:90
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2* Generic $10.00$25.00Q:90
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 42%N/AQ:90
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   2* Generic $10.00$25.00Q:90
/30Days
CLONAZEPAM 2 MG ODT TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 42%N/AQ:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2* Generic $10.00$25.00Q:300
/30Days
CLONIDINE 0.1 MG/DAY PATCH [Catapres-TTS]   4 Non-Preferred Drug 42%N/AQ:4
/28Days
CLONIDINE 0.2 MG/DAY PATCH [Catapres-TTS]   4 Non-Preferred Drug 42%N/AQ:4
/28Days
CLONIDINE 0.3 MG/DAY PATCH [Catapres-TTS]   4 Non-Preferred Drug 42%N/AQ:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL 0.1 MG TABLET [Catapres]   2* Generic $10.00$25.00None
CLONIDINE HCL 0.2 MG TABLET   2* Generic $10.00$25.00None
CLONIDINE HCL 0.3 MG TABLET [Catapres]   2* Generic $10.00$25.00None
CLONIDINE HCL ER 0.1 MG TABLET ER 12H [Kapvay]   4 Non-Preferred Drug 42%N/ANone
CLOPIDOGREL 75 MG TABLET [Plavix]   1* Preferred Generic $1.00$2.50Q:30
/30Days
CLORAZEPATE 15 MG TABLET [Tranxene]   4 Non-Preferred Drug 42%N/AP Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET [Tranxene]   4 Non-Preferred Drug 42%N/AP Q:90
/30Days
CLORAZEPATE 7.5 MG TABLET [Tranxene T-Tab]   4 Non-Preferred Drug 42%N/AP Q:360
/30Days
CLOTRIMAZOLE 1% SOLUTION [Lotrimin AF]   3 Preferred Brand $47.00$117.50Q:30
/28Days
CLOTRIMAZOLE 1% TOPICAL CREAM (G) [Mycozyl AC]   3 Preferred Brand $47.00$117.50Q:45
/28Days
CLOTRIMAZOLE 10 MG TROCHE [Mycelex Troche]   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOTRIMAZOLE-BETAMETHASONE CREAM (G) [Lotrisone]   3 Preferred Brand $47.00$117.50Q:45
/28Days
CLOTRIMAZOLE-BETAMETHASONE LOT   4 Non-Preferred Drug 42%N/AQ:60
/28Days
CLOZAPINE 100 MG TABLET [Clozaril]   3 Preferred Brand $47.00$117.50None
CLOZAPINE 200 MG TABLET [Clozaril]   3 Preferred Brand $47.00$117.50None
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand $47.00$117.50None
CLOZAPINE 50 MG TABLET [Clozaril]   3 Preferred Brand $47.00$117.50None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%N/ANone
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%N/ANone
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%N/ANone
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%N/ANone
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COARTEM 20MG-120MG   4 Non-Preferred Drug 42%N/ANone
COLCHICINE 0.6 MG TABLET [Colcrys]   3 Preferred Brand $47.00$117.50None
COLESEVELAM 625 MG TABLET [WelChol]   4 Non-Preferred Drug 42%N/ANone
COLESEVELAM HCL 3.75 G POWDER PACKET [Welchol Powder]   4 Non-Preferred Drug 42%N/ANone
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   4 Non-Preferred Drug 42%N/AP Q:30
/10Days
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 42%N/AQ:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PACK   5 Specialty Tier 28%N/AP Q:56
/28Days
COMETRIQ 140 MG DAILY-DOSE PACK   5 Specialty Tier 28%N/AP Q:112
/28Days
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 28%N/AP Q:84
/28Days
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   4 Non-Preferred Drug 42%N/ANone
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Drug 42%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CONSTULOSE 10 GM/15 ML SOLUTION   2* Generic $10.00$25.00None
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 28%N/AP Q:60
/30Days
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 28%N/AP Q:60
/30Days
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 42%N/AQ:60
/30Days
CORLANOR 5 MG/5 ML ORAL SOLUTION   4 Non-Preferred Drug 42%N/AQ:450
/30Days
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 42%N/AQ:60
/30Days
COSENTYX 300 MG DOSE-2 PENS   5 Specialty Tier 28%N/AP Q:10
/28Days
COSENTYX 300 MG DOSE-2 SYRINGE   5 Specialty Tier 28%N/AP Q:10
/28Days
COSENTYX 75 MG/0.5 ML SYRINGE   5 Specialty Tier 28%N/AP Q:2.5
/28Days
COTELLIC 20 MG TABLET   5 Specialty Tier 28%N/AP Q:63
/28Days
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOTTLE   3 Preferred Brand $47.00$117.50None
CREON DR 12,000 UNIT CAPSULE   3 Preferred Brand $47.00$117.50None
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $47.00$117.50None
CREON DR 6,000 UNIT CAPSULE   3 Preferred Brand $47.00$117.50None
CRESEMBA 186 MG CAPSULE   4 Non-Preferred Drug 42%N/AP
CRESEMBA 74.5 MG CAPSULE   5 Specialty Tier 28%N/AP
CROMOLYN 100 MG/5 ML ORAL CONC [Gastrocrom]   4 Non-Preferred Drug 42%N/ANone
CROMOLYN 20 MG/2 ML NEB SOLN AMPUL-NEB [Intal]   4 Non-Preferred Drug 42%N/AP
CROMOLYN SODIUM 4% 40MG 10ML BOTTLE   2* Generic $10.00$25.00None
CYCLOBENZAPRINE 10 MG TABLET [Flexeril]   4 Non-Preferred Drug 42%N/AP
CYCLOBENZAPRINE 5 MG TABLET [Flexeril]   4 Non-Preferred Drug 42%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOPHOSPHAMIDE 25 MG CAPSULE   3 Preferred Brand $47.00$117.50P
CYCLOPHOSPHAMIDE 25 MG TABLET [Cytoxan]   3 Preferred Brand $47.00$117.50P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   3 Preferred Brand $47.00$117.50P
CYCLOPHOSPHAMIDE 50 MG TABLET [Cytoxan]   3 Preferred Brand $47.00$117.50P
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 42%N/AP
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 42%N/AP
CYCLOSPORINE MODIFIED 100 MG CAPSULE [Neoral]   4 Non-Preferred Drug 42%N/AP
CYCLOSPORINE MODIFIED 25 MG CAPSULE [Neoral]   4 Non-Preferred Drug 42%N/AP
CYCLOSPORINE MODIFIED 50 MG CAPSULE [Neoral]   4 Non-Preferred Drug 42%N/AP
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOTTLE   4 Non-Preferred Drug 42%N/AP
CYLTEZO(CF) 10 MG/0.2 ML SYRINGEKIT   5 Specialty Tier 28%N/AP Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYLTEZO(CF) 20 MG/0.4 ML SYRINGEKIT   5 Specialty Tier 28%N/AP Q:2
/28Days
CYLTEZO(CF) 40 MG/0.4 ML SYRNGE KIT [Yuflyma]   5 Specialty Tier 28%N/AP Q:4
/28Days
CYLTEZO(CF) 40 MG/0.8 ML SYRINGE KIT   5 Specialty Tier 28%N/AP Q:4
/28Days
CYLTEZO(CF) PEN 40 MG/0.4 ML PEN INJECTOR KIT [Yuflyma]   5 Specialty Tier 28%N/AP Q:4
/28Days
CYLTEZO(CF) PEN 40 MG/0.8 ML PEN INJECTOR KIT   5 Specialty Tier 28%N/AP Q:4
/28Days
CYLTEZO(CF) PEN CRH-UC-HS 40MG PEN INJECTOR KIT   5 Specialty Tier 28%N/AP Q:6
/180Days
CYLTEZO(CF) PEN CRH-UC-HS 40MG PEN INJECTOR KIT [Yuflyma]   5 Specialty Tier 28%N/AP Q:6
/180Days
CYLTEZO(CF) PEN PSORIA-UV 40MG PEN INJECTOR KIT [Yuflyma]   5 Specialty Tier 28%N/AP Q:4
/180Days
CYLTEZO(CF) PEN PSORIASIS 40MG PEN INJECTOR KIT   5 Specialty Tier 28%N/AP Q:4
/180Days
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 28%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 42%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 42%N/AP
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 28%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2024 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 $545 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 $5,030) 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 2024)

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
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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.