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2024 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
Tier 1 (235)
Tier 2 (713)
Tier 3 (686)
Tier 4 (985)
Tier 5 (571)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

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2024 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
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 Plus (PDP) (S7126-010-0)
Formulary Drugs Starting with the Letter H

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
HALOBETASOL PROP 0.05% CREAM   4 Non-Preferred Drug 40%N/ANone
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE   4 Non-Preferred Drug 40%N/ANone
HALOPERIDOL 0.5 MG TABLET [Haldol]   2 Generic $5.00$12.50None
HALOPERIDOL 1 MG TABLET [Haldol]   2 Generic $5.00$12.50None
HALOPERIDOL 10 MG TABLET   2 Generic $5.00$12.50None
HALOPERIDOL 2 MG TABLET [Haldol]   2 Generic $5.00$12.50None
HALOPERIDOL 20MG TABLET (100 CT)   3 Preferred Brand 17%17%None
HALOPERIDOL 5 MG TABLET [Haldol]   2 Generic $5.00$12.50None
HALOPERIDOL DEC 100 MG/ML VIAL [Haldol Decanoate]   4 Non-Preferred Drug 40%N/ANone
HALOPERIDOL DEC 50 MG/ML VIAL [Haldol Decanoate]   4 Non-Preferred Drug 40%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HALOPERIDOL DEC 50 MG/ML VIAL [Haldol Decanoate]   4 Non-Preferred Drug 40%N/ANone
HALOPERIDOL DEC 500 MG/5 ML VIAL [Haldol Decanoate]   4 Non-Preferred Drug 40%N/ANone
HALOPERIDOL LAC 2 MG/ML CONC   2 Generic $5.00$12.50None
HALOPERIDOL LAC 5 MG/ML VIAL   4 Non-Preferred Drug 40%N/ANone
HARVONI 33.75-150 MG PELLET PACKET   5 Specialty Tier 25%N/AP Q:28
/28Days
HARVONI 45-200 MG PELLET PACKET   5 Specialty Tier 25%N/AP Q:56
/28Days
HARVONI 90-400 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
HAVRIX 1,440 UNITS/ML SYRINGE   1 Preferred Generic $1.00$2.50None
HAVRIX HEPATITIS A VACCINE INJECTION   3 Preferred Brand 17%17%None
HEATHER 0.35 MG TABLET [Sharobel 28-Day]   2 Generic $5.00$12.50None
HEPARIN 10,000 UNIT/10 ML VIAL   3 Preferred Brand 17%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HEPARIN SOD 20,000 UNIT/ML VIAL   3 Preferred Brand 17%17%None
HEPARIN SOD 5,000 UNIT/ML VIAL   3 Preferred Brand 17%17%None
HEPARIN SODIUM INJECTION   3 Preferred Brand 17%17%None
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax]   1 Preferred Generic $1.00$2.50P
HEPLISAV-B 20 MCG/0.5 ML SYRINGE   1 Preferred Generic $1.00$2.50P
Hiberix Haemophilus B Injectable 0.5mL Prefilled Syringe 10/Pk   3 Preferred Brand 17%17%None
HUMALOG 100 UNIT/ML VIAL   3 Preferred Brand 17%17%None
HUMALOG 100 UNITS/ML CARTRIDGE   3 Preferred Brand 17%17%None
HUMALOG 200 UNITS/ML KWIKPEN   4 Non-Preferred Drug 40%N/ANone
HUMALOG JR 100 UNIT/ML KWIKPEN   3 Preferred Brand 17%17%None
HUMALOG KWIKPEN INJECTION   3 Preferred Brand 17%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMALOG MIX 75/25 VIAL   3 Preferred Brand 17%17%None
HUMALOG MIX KWIKPEN INJECTION   3 Preferred Brand 17%17%None
HUMALOG MIX KWIKPEN INJECTION SUSPENSION   3 Preferred Brand 17%17%None
HUMIRA 10 MG/0.1 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
Humira 2 KIT per CARTON / 1 KIT in 1 KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 20 MG/0.2 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
HUMIRA 40 MG/0.4 ML PEN IJ KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 40 MG/0.4 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 40 MG/0.8 ML PEN   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA(CF) PEN 80 MG/0.8 ML PEN IJ KIT   5 Specialty Tier 25%N/AP Q:2
/28Days
HUMIRA(CF) PEN CRHN-UC-HS 80MG PEN IJ KIT   5 Specialty Tier 25%N/AP Q:3
/180Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMIRA(CF) PEN PEDI UC 80 MG PEN IJ KIT   5 Specialty Tier 25%N/AP Q:4
/180Days
HUMIRA(CF) PEN PS-UV-AHS 80-40 PEN IJ KIT   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMULIN 70/30 KWIKPEN   3 Preferred Brand 17%17%None
HUMULIN 70/30 VIAL   3 Preferred Brand 17%17%None
HUMULIN N 100 UNITS/ML KWIKPEN   3 Preferred Brand 17%17%None
HUMULIN N 100U/ML VIAL   3 Preferred Brand 17%17%None
HUMULIN R 100U/ML VIAL   3 Preferred Brand 17%17%None
HUMULIN R 500 UNITS/ML KWIKPEN   4 Non-Preferred Drug 40%N/ANone
HUMULIN R 500U/ML VIAL   4 Non-Preferred Drug 40%N/ANone
HYDRALAZINE 10 MG TABLET [Apresoline]   2 Generic $5.00$12.50None
HYDRALAZINE 100 MG TABLET [Apresoline]   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDRALAZINE 25 MG TABLET   2 Generic $5.00$12.50None
HYDRALAZINE 50 MG TABLET   2 Generic $5.00$12.50None
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE [Microzide]   1 Preferred Generic $1.00$2.50None
HYDROCHLOROTHIAZIDE 12.5 MG TABLET   1 Preferred Generic $1.00$2.50None
HYDROCHLOROTHIAZIDE 25 MG TABLET   1 Preferred Generic $1.00$2.50None
HYDROCHLOROTHIAZIDE 50 MG TABLET [Zide]   1 Preferred Generic $1.00$2.50None
HYDROCODONE-ACETAMIN 10-300 MG TABLET [Xodol]   3 Preferred Brand 17%17%Q:390
/30Days
HYDROCODONE-ACETAMIN 10-325 MG TABLET [Norco]   3 Preferred Brand 17%17%Q:360
/30Days
HYDROCODONE-ACETAMIN 5-300 MG TABLET [Xodol]   3 Preferred Brand 17%17%Q:390
/30Days
HYDROCODONE-ACETAMIN 5-325 MG TABLET [Norco]   3 Preferred Brand 17%17%Q:360
/30Days
HYDROCODONE-ACETAMIN 7.5-300 TABLET [Xodol]   3 Preferred Brand 17%17%Q:390
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCODONE-ACETAMIN 7.5-325 TABLET [Norco]   3 Preferred Brand 17%17%Q:360
/30Days
HYDROCODONE-ACETAMN 7.5-325/15 SOLUTION [Hycet]   4 Non-Preferred Drug 40%N/AQ:5550
/30Days
HYDROCODONE-IBUPROFEN 7.5-200 TABLET [Vicoprofen]   3 Preferred Brand 17%17%Q:50
/30Days
HYDROCORTISON-ACETIC ACID SOLUTION DROPS [VoSoL HC]   4 Non-Preferred Drug 40%N/ANone
HYDROCORTISONE 1% CREAM   2 Generic $5.00$12.50None
HYDROCORTISONE 1% OINTMENT   2 Generic $5.00$12.50None
HYDROCORTISONE 10 MG TABLET [Hydrocortone]   2 Generic $5.00$12.50None
Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort]   2 Generic $5.00$12.50None
HYDROCORTISONE 100 MG/60 ML   4 Non-Preferred Drug 40%N/ANone
HYDROCORTISONE 2.5% CREAM /PE APP [Proctozone-HC]   2 Generic $5.00$12.50None
HYDROCORTISONE 2.5% LOTION   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCORTISONE 2.5% OINTMENT   2 Generic $5.00$12.50None
HYDROCORTISONE 20 MG TABLET [Cortef]   2 Generic $5.00$12.50None
HYDROCORTISONE 5 MG TABLET [Cortef]   2 Generic $5.00$12.50None
HYDROMORPHONE 1 MG/ML SOLUTION LIQUID [Dilaudid]   4 Non-Preferred Drug 40%N/AQ:2400
/30Days
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP]   4 Non-Preferred Drug 40%N/ANone
HYDROMORPHONE 2 MG TABLET [Dilaudid]   3 Preferred Brand 17%17%Q:180
/30Days
HYDROMORPHONE 4 MG TABLET [Dilaudid]   3 Preferred Brand 17%17%Q:180
/30Days
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP]   4 Non-Preferred Drug 40%N/ANone
HYDROMORPHONE 8 MG TABLET [Dilaudid]   3 Preferred Brand 17%17%Q:180
/30Days
HYDROMORPHONE HCL ER 12 MG TABLET 24H [Exalgo]   4 Non-Preferred Drug 40%N/AP Q:60
/30Days
HYDROMORPHONE HCL ER 16 MG TABLET 24H [Exalgo]   4 Non-Preferred Drug 40%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROMORPHONE HCL ER 32 MG TABLET 24H [Exalgo]   4 Non-Preferred Drug 40%N/AP Q:60
/30Days
HYDROMORPHONE HCL ER 8 MG TABLET 24H [Exalgo]   4 Non-Preferred Drug 40%N/AP Q:60
/30Days
HYDROXYCHLOROQUINE 200 MG TABLET [Quineprox]   3 Preferred Brand 17%17%None
HYDROXYUREA 500 MG CAPSULE   2 Generic $5.00$12.50None
HYDROXYZINE HCL 10 MG TABLET [Rezine]   3 Preferred Brand 17%17%P
HYDROXYZINE HCL 25 MG TABLET [Atarax]   3 Preferred Brand 17%17%P
HYDROXYZINE HCL 50 MG TABLET [Atarax]   3 Preferred Brand 17%17%P
HYRIMOZ(CF) 10 MG/0.1 ML SYRINGE   5 Specialty Tier 25%N/AP Q:0.2
/28Days
HYRIMOZ(CF) 20 MG/0.2 ML SYRINGE   5 Specialty Tier 25%N/AP Q:0.4
/28Days
HYRIMOZ(CF) 40 MG/0.4 ML SYRINGE   5 Specialty Tier 25%N/AP Q:1.6
/28Days
HYRIMOZ(CF) PEN 40 MG/0.4 ML PEN INJECTOR   5 Specialty Tier 25%N/AP Q:1.6
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYRIMOZ(CF) PEN 80 MG/0.8 ML PEN INJECTOR   5 Specialty Tier 25%N/AP Q:1.6
/28Days
HYRIMOZ(CF) PEN CROHN-UC 80 MG PEN INJECTOR   5 Specialty Tier 25%N/AP Q:2.4
/180Days
HYRIMOZ(CF) PEN PSORIA 80-40MG PEN INJECTOR   5 Specialty Tier 25%N/AP Q:1.6
/180Days

Chart Legend:

Below are a few notes to help you understand the above 2024 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 $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.