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2024 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Mutual of Omaha Rx Essential (PDP) (S7126-107-0)
Tier 1 (289)
Tier 2 (649)
Tier 3 (714)
Tier 4 (998)
Tier 5 (572)
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2024 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Essential (PDP) (S7126-107-0)
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 Essential (PDP) (S7126-107-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 5 which includes: DC DE MD
Drugs Starting with Letter M

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   1* Preferred Generic $0.00$0.00None
MAGNESIUM SULFATE 50% SYRINGE   4 Non-Preferred Drug 48%N/ANone
MAGNESIUM SULFATE 50% VIAL   4 Non-Preferred Drug 48%N/ANone
MALATHION 0.5% LOTION   4 Non-Preferred Drug 48%N/ANone
MARAVIROC 150 MG TABLET [Selzentry]   5 Specialty Tier 25%N/ANone
MARAVIROC 300 MG TABLET [Selzentry]   5 Specialty Tier 25%N/ANone
MARLISSA-28 TABLET   2 Generic $15.00$37.50None
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Drug 48%N/ANone
MATULANE 50 MG CAPSULE   5 Specialty Tier 25%N/ANone
MATZIM LA 180 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
MATZIM LA 240 MG TABLET   3 Preferred Brand 20%20%None
MATZIM LA 300 MG TABLET   3 Preferred Brand 20%20%None
MATZIM LA 360 MG TABLET   3 Preferred Brand 20%20%None
MATZIM LA 420 MG TABLET   3 Preferred Brand 20%20%None
MECLIZINE 12.5 MG TABLET [Antivert]   2 Generic $15.00$37.50None
MECLIZINE 25 MG TABLET [Meni-D]   2 Generic $15.00$37.50None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   2 Generic $15.00$37.50None
MEDROXYPROGESTERONE 150 MG/ML SYRINGE [Depo-Provera]   2 Generic $15.00$37.50None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   2 Generic $15.00$37.50None
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   2 Generic $15.00$37.50None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEFLOQUINE HCL 250 MG TABLET   2 Generic $15.00$37.50None
MEGESTROL 20 MG TABLET [Megace]   3 Preferred Brand 20%20%P
MEGESTROL 40 MG TABLET   3 Preferred Brand 20%20%P
MEGESTROL 625 MG/5 ML ORAL SUSPENSION [Megace ES]   4 Non-Preferred Drug 48%N/AP
MEGESTROL ACET 40 MG/ML ORAL SUSPENSION [Megace]   3 Preferred Brand 20%20%P
MEKINIST 0.05 MG/ML SOLUTION RECON   5 Specialty Tier 25%N/AP Q:1200
/30Days
MEKINIST 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
MEKINIST 2 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
MEKTOVI 15 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
MELOXICAM 15 MG TABLET   1* Preferred Generic $0.00$0.00Q:30
/30Days
MELOXICAM 7.5 MG TABLET [Mobic]   1* Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEMANTINE HCL 10 MG TABLET [Namenda]   3 Preferred Brand 20%20%P
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   4 Non-Preferred Drug 48%N/AP
MEMANTINE HCL 5 MG TABLET [Namenda]   3 Preferred Brand 20%20%P
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR]   4 Non-Preferred Drug 48%N/AP
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda XR]   4 Non-Preferred Drug 48%N/AP
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda XR]   4 Non-Preferred Drug 48%N/AP
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR]   4 Non-Preferred Drug 48%N/AP
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL   1* Preferred Generic $0.00$0.00None
MENEST 0.3MG TABLET   3 Preferred Brand 20%20%None
MENEST 0.625MG TABLET   3 Preferred Brand 20%20%None
MENEST 1.25MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MENEST 2.5 MG TABLET   3 Preferred Brand 20%20%None
MENQUADFI VIAL   1* Preferred Generic $0.00$0.00None
MENVEO A-C-Y-W-135-DIP VIAL   1* Preferred Generic $0.00$0.00None
MERCAPTOPURINE 50 MG TABLET   4 Non-Preferred Drug 48%N/ANone
MEROPENEM IV 1 GM VIAL [Merrem]   4 Non-Preferred Drug 48%N/AP Q:30
/10Days
MEROPENEM IV 500 MG VIAL [Merrem]   4 Non-Preferred Drug 48%N/AP Q:10
/10Days
MESALAMINE 1,000 MG SUPP.RECT [Canasa]   4 Non-Preferred Drug 48%N/ANone
MESALAMINE 4 GM/60 ML ENEMA   4 Non-Preferred Drug 48%N/ANone
MESALAMINE 800 MG DR TABLET DR [Asacol HD]   4 Non-Preferred Drug 48%N/ANone
MESALAMINE DR 1.2 GM TABLET   4 Non-Preferred Drug 48%N/ANone
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol]   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESALAMINE ER 0.375 GRAM CAPSULE ER 24H [Apriso]   4 Non-Preferred Drug 48%N/ANone
MESALAMINE ER 500 MG CAPSULE ER [Pentasa]   4 Non-Preferred Drug 48%N/ANone
MESNEX 400MG TABLET   5 Specialty Tier 25%N/ANone
METFORMIN HCL 1,000 MG TABLET [Glucophage]   1* Preferred Generic $0.00$0.00Q:75
/30Days
METFORMIN HCL 500 MG TABLET [Glucophage]   1* Preferred Generic $0.00$0.00Q:150
/30Days
METFORMIN HCL 850 MG TABLET [Glucophage]   1* Preferred Generic $0.00$0.00Q:90
/30Days
METFORMIN HCL ER 500 MG TABLET 24H [Glumetza]   1* Preferred Generic $0.00$0.00Q:120
/30Days
METFORMIN HCL ER 750 MG TABLET 24H [Glucophage XR]   1* Preferred Generic $0.00$0.00Q:60
/30Days
METHADONE 10 MG/5 ML SOLUTION   3 Preferred Brand 20%20%P Q:600
/30Days
METHADONE 5 MG/5 ML SOLUTION   3 Preferred Brand 20%20%P Q:1200
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   3 Preferred Brand 20%20%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHADONE HCL 5 MG TABLET [Methadose]   3 Preferred Brand 20%20%P Q:240
/30Days
METHAZOLAMIDE 25 MG TABLET [Neptazane]   4 Non-Preferred Drug 48%N/ANone
METHAZOLAMIDE 50 MG TABLET [Neptazane]   4 Non-Preferred Drug 48%N/ANone
METHENAMINE HIPP 1 GM TABLET [Urex]   4 Non-Preferred Drug 48%N/ANone
METHIMAZOLE 10 MG TABLET [Tapazole]   1* Preferred Generic $0.00$0.00None
METHIMAZOLE 5 MG TABLET [Tapazole]   1* Preferred Generic $0.00$0.00None
METHOCARBAMOL 500 MG TABLET [Robaxin]   3 Preferred Brand 20%20%None
METHOCARBAMOL 750 MG TABLET [Robaxin]   3 Preferred Brand 20%20%None
METHOTREXATE 2.5 MG TABLET [Rheumatrex]   2 Generic $15.00$37.50P
METHOTREXATE 50 MG/2 ML VIAL   3 Preferred Brand 20%20%P
METHOTREXATE 50 MG/2 ML VIAL   3 Preferred Brand 20%20%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Methoxsalen 10 mg Capsule [8-MOP]   5 Specialty Tier 25%N/ANone
METHSUXIMIDE 300 MG CAPSULE [Celontin]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE 10 MG CHEWABLE TABLET [Methylin]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE 10 MG TABLET [Ritalin]   3 Preferred Brand 20%20%None
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE 2.5 MG CHEWABLE TABLET [Methylin]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE 20 MG TABLET [Ritalin]   3 Preferred Brand 20%20%None
METHYLPHENIDATE 5 MG CHEWABLE TABLET [Methylin]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE 5 MG TABLET [Ritalin]   3 Preferred Brand 20%20%None
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE LA 10 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE LA 30 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 48%N/ANone
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 48%N/ANone
METHYLPREDNISOLONE 16 MG TABLET [Medrol Dosepak]   2 Generic $15.00$37.50P
METHYLPREDNISOLONE 32 MG TABLET [Medrol]   2 Generic $15.00$37.50P
METHYLPREDNISOLONE 4 MG DOSEPK   2 Generic $15.00$37.50None
METHYLPREDNISOLONE 4 MG TABLET   2 Generic $15.00$37.50P
METHYLPREDNISOLONE 8 MG TABLET [Medrol]   2 Generic $15.00$37.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metoclopramide 10mg/1 500 TABLET BOTTLE   2 Generic $15.00$37.50None
METOCLOPRAMIDE 5 MG TABLET   2 Generic $15.00$37.50None
METOCLOPRAMIDE 5 MG/5 ML SOLUTION   2 Generic $15.00$37.50None
METOLAZONE 10 MG TABLET [Zaroxolyn]   3 Preferred Brand 20%20%None
METOLAZONE 2.5 MG TABLET [Zaroxolyn]   3 Preferred Brand 20%20%None
METOLAZONE 5 MG TABLET [Zaroxolyn]   3 Preferred Brand 20%20%None
METOPROLOL SUCC ER 100 MG TABLET 24H [Toprol XL]   1* Preferred Generic $0.00$0.00None
METOPROLOL SUCC ER 200 MG TABLET ER 24H [Toprol XL]   1* Preferred Generic $0.00$0.00None
METOPROLOL SUCC ER 25 MG TABLET 24H [Toprol XL]   1* Preferred Generic $0.00$0.00None
METOPROLOL SUCC ER 50 MG TABLET ER 24H [Toprol XL]   1* Preferred Generic $0.00$0.00None
METOPROLOL TARTRATE 100 MG TABLET [Lopressor]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL TARTRATE 25 MG TABLET   1* Preferred Generic $0.00$0.00None
METOPROLOL TARTRATE 37.5 MG TABLET   2 Generic $15.00$37.50None
METOPROLOL TARTRATE 50 MG TABLET [Lopressor]   1* Preferred Generic $0.00$0.00None
METOPROLOL TARTRATE 75 MG TABLET   2 Generic $15.00$37.50None
METOPROLOL-HCTZ 100-25 MG TABLET [Lopressor HCT]   2 Generic $15.00$37.50None
METOPROLOL-HCTZ 50-25 MG TABLET [Lopressor HCT]   2 Generic $15.00$37.50None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   2 Generic $15.00$37.50None
METRONIDAZOLE 0.75% CREAM (G) [Vitazol]   4 Non-Preferred Drug 48%N/ANone
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug 48%N/ANone
METRONIDAZOLE 250 MG TABLET [Flagyl]   2 Generic $15.00$37.50None
METRONIDAZOLE 500 MG TABLET [Flagyl]   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   4 Non-Preferred Drug 48%N/AP
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug 48%N/ANone
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   4 Non-Preferred Drug 48%N/ANone
METRONIDAZOLE VAGINAL 0.75% GEL W/APPL [Vandazole]   3 Preferred Brand 20%20%None
METYROSINE 250 MG CAPSULE [Demser]   5 Specialty Tier 25%N/AP
MICAFUNGIN 100 MG VIAL [Mycamine]   5 Specialty Tier 25%N/ANone
MICAFUNGIN 50 MG VIAL [Mycamine]   5 Specialty Tier 25%N/ANone
MICROGESTIN 21 1-20 TABLET [Microgestin 1/20]   2 Generic $15.00$37.50None
MICROGESTIN 21 1.5-30 TABLET [Microgestin 1.5/30]   2 Generic $15.00$37.50None
MICROGESTIN FE 1-20 TABLET [Tarina Fe 1/20]   2 Generic $15.00$37.50None
MICROGESTIN FE 1.5-30 TABLET [Microgestin Fe 1.5/30]   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIDODRINE HCL 10 MG TABLET   3 Preferred Brand 20%20%None
MIDODRINE HCL 2.5 MG TABLET [ProAmatine]   3 Preferred Brand 20%20%None
MIDODRINE HCL 5 MG TABLET [ProAmatine]   3 Preferred Brand 20%20%None
MIFEPRISTONE 300 MG TABLET [Korlym]   5 Specialty Tier 25%N/AP
MILI 0.25-0.035 MG TABLET [VyLibra]   2 Generic $15.00$37.50None
MIMVEY 1-0.5 MG TABLET   3 Preferred Brand 20%20%None
MINOCYCLINE 100 MG CAPSULE   2 Generic $15.00$37.50None
MINOCYCLINE 50 MG CAPSULE [Minocin PAC]   2 Generic $15.00$37.50None
MINOCYCLINE 75 MG CAPSULE [Minocin]   2 Generic $15.00$37.50None
MINOCYCLINE HCL 100 MG TABLET [Myrac]   4 Non-Preferred Drug 48%N/ANone
MINOCYCLINE HCL 50 MG TABLET [Myrac]   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE HCL 75 MG TABLET [Myrac]   4 Non-Preferred Drug 48%N/ANone
MINOXIDIL 10 MG TABLET [Loniten]   2 Generic $15.00$37.50None
MINOXIDIL 2.5 MG TABLET [Loniten]   2 Generic $15.00$37.50None
MIRABEGRON ER 25 MG TABLET 24H [Myrbetriq]   3 Preferred Brand 20%20%None
MIRABEGRON ER 50 MG TABLET 24H [Myrbetriq]   3 Preferred Brand 20%20%None
MIRTAZAPINE 15 MG ODT   3 Preferred Brand 20%20%None
MIRTAZAPINE 15 MG TABLET [Remeron]   1* Preferred Generic $0.00$0.00None
MIRTAZAPINE 30 MG ODT TABLET RAPDIS [Remeron SolTab]   3 Preferred Brand 20%20%None
MIRTAZAPINE 30 MG TABLET [Remeron]   1* Preferred Generic $0.00$0.00None
MIRTAZAPINE 45 MG ODT   3 Preferred Brand 20%20%None
MIRTAZAPINE 45 MG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRTAZAPINE 7.5 MG TABLET   2 Generic $15.00$37.50None
MISOPROSTOL 100 MCG TABLET [Cytotec]   3 Preferred Brand 20%20%None
MISOPROSTOL 200 MCG TABLET [Cytotec]   3 Preferred Brand 20%20%None
MODAFINIL 100 MG TABLET [Provigil]   3 Preferred Brand 20%20%P Q:30
/30Days
MODAFINIL 200 MG TABLET [Provigil]   3 Preferred Brand 20%20%P Q:60
/30Days
MOEXIPRIL HCL 15 MG TABLET [Univasc]   3 Preferred Brand 20%20%None
MOEXIPRIL HCL 7.5 MG TABLET   3 Preferred Brand 20%20%None
MOLINDONE HCL 10 MG TABLET   4 Non-Preferred Drug 48%N/ANone
MOLINDONE HCL 25 MG TABLET   4 Non-Preferred Drug 48%N/ANone
MOLINDONE HCL 5 MG TABLET   4 Non-Preferred Drug 48%N/ANone
MOMETASONE FUROATE 0.1% CREAM (G) [Elocon]   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOMETASONE FUROATE 0.1% OINTMENT [Elocon]   2 Generic $15.00$37.50None
MOMETASONE FUROATE 0.1% SOLUTION   2 Generic $15.00$37.50None
MONTELUKAST SOD 10 MG TABLET [Singulair]   1* Preferred Generic $0.00$0.00None
MONTELUKAST SOD 4 MG CHEWABLE TABLET [Singulair]   1* Preferred Generic $0.00$0.00None
MONTELUKAST SOD 4 MG GRANULES [Singulair]   4 Non-Preferred Drug 48%N/ANone
MONTELUKAST SOD 5 MG CHEWABLE TABLET [Singulair]   1* Preferred Generic $0.00$0.00None
MORPHINE SULF 10 MG/5 ML SOLUTION [MSIR]   3 Preferred Brand 20%20%Q:900
/30Days
MORPHINE SULF 100 MG/5 ML CONC SOLUTION [Roxanol-T]   3 Preferred Brand 20%20%Q:900
/30Days
MORPHINE SULF 20 MG/5 ML SOLUTION [MSIR]   3 Preferred Brand 20%20%Q:900
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Preferred Brand 20%20%P Q:120
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Preferred Brand 20%20%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULF ER 200 MG TABLET   3 Preferred Brand 20%20%P Q:120
/30Days
MORPHINE SULF ER 30 MG TABLET   3 Preferred Brand 20%20%P Q:120
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Preferred Brand 20%20%P Q:120
/30Days
MORPHINE SULFATE IR 15 MG TABLET [MSIR]   3 Preferred Brand 20%20%Q:180
/30Days
MORPHINE SULFATE IR 30 MG TABLET [MSIR]   3 Preferred Brand 20%20%Q:180
/30Days
MOUNJARO 10 MG/0.5 ML PEN INJECTOR   3 Preferred Brand 20%20%P Q:2
/28Days
MOUNJARO 12.5 MG/0.5 ML PEN INJECTOR   3 Preferred Brand 20%20%P Q:2
/28Days
MOUNJARO 15 MG/0.5 ML PEN INJECTOR   3 Preferred Brand 20%20%P Q:2
/28Days
MOUNJARO 2.5 MG/0.5 ML PEN INJECTOR   3 Preferred Brand 20%20%P Q:2
/28Days
MOUNJARO 5 MG/0.5 ML PEN INJECTOR   3 Preferred Brand 20%20%P Q:2
/28Days
MOUNJARO 7.5 MG/0.5 ML PEN INJECTOR   3 Preferred Brand 20%20%P Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOVANTIK 12.5 MG TABLET   3 Preferred Brand 20%20%Q:30
/30Days
MOVANTIK 25 MG TABLET   3 Preferred Brand 20%20%Q:30
/30Days
MOXIFLOXACIN 0.5% EYE DROPS [Vigamox]   3 Preferred Brand 20%20%None
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.]   4 Non-Preferred Drug 48%N/AP
MOXIFLOXACIN HCL 400 MG TABLET [Avelox ABC Pack]   3 Preferred Brand 20%20%None
MULTIPLE ELECTROLYTES T1 PH5.5 IV SOLUTION   3 Preferred Brand 20%20%None
MUPIROCIN 2% OINTMENT [Centany AT]   2 Generic $15.00$37.50Q:44
/30Days
MYALEPT 11.3 MG (5 MG/ML) VIAL   5 Specialty Tier 25%N/AP
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 25%N/AP
MYCOPHENOLATE 250 MG CAPSULE [CellCept]   3 Preferred Brand 20%20%P
MYCOPHENOLATE 500 MG TABLET [CellCept]   3 Preferred Brand 20%20%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MYCOPHENOLIC ACID DR 180 MG TABLET DR [Myfortic]   4 Non-Preferred Drug 48%N/AP
MYCOPHENOLIC ACID DR 360 MG TABLET DR [Myfortic]   4 Non-Preferred Drug 48%N/AP
MYFEMBREE 40 MG-1 MG-0.5 MG TABLET   5 Specialty Tier 25%N/AP
MYRBETRIQ ER 25 MG TABLET   3 Preferred Brand 20%20%None
MYRBETRIQ ER 50 MG TABLET   3 Preferred Brand 20%20%None
MYRBETRIQ ER 8 MG/ML SUSP ER REC   3 Preferred Brand 20%20%None

Chart Legend:

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