Mutual of Omaha Rx Plus (PDP) Formulary



Below is the 2022 Formulary, or prescription drug list, from Omaha Health Insurance Company for Mutual of Omaha Rx Plus (PDP)( S7126-022). A formulary is a list of prescription medications that are covered under Omaha Health Insurance Company's 2022 Medicare Part-D in Oklahoma.

This Mutual of Omaha Rx Plus (PDP) plan has a $480 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column.

The Initial Coverage Limit (ICL) for this plan is $4430. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible)

You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart.

In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Mutual of Omaha Rx Plus (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.




Plan Name:Mutual of Omaha Rx Plus (PDP)
Plan ID: S7126-022
Formulary
Provider: Omaha Health Insurance Company
Plan Year:2022
Premium:$84.60
Deductible:$480
Initial Coverage Limit:$4430
Coverage Area:Oklahoma


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Bacitracin Zinc And Polymyxin B Sulfate
2Y$3$10NANN
Baclofen
3Y17%19%NANN
Balsalazide Disodium
4Y41%43%41%NN
Balversa
525%25%25%YN
Banzel
525%25%25%YN
Baqsimi
3Y17%19%NANN
Baraclude
4Y41%43%41%600/30NN
Bcg Vaccine
3Y17%19%NANN
Benazepril Hydrochloride And Hydrochlorothiazide
2Y$3$10NANN
Benznidazole
4Y41%43%41%NN
Benztropine Mesylate
3Y17%19%NAYN
Betamethasone Dipropionate
4Y41%43%41%NN
Betamethasone Valerate
4Y41%43%41%NN
Betaxolol Hydrochloride
4Y41%43%41%NN
Bethanechol Chloride
3Y17%19%NANN
Bexarotene
525%25%25%YN
Bexsero
3Y17%19%NANN
Bicillin L-a
4Y41%43%41%YN
Biktarvy
525%25%25%NN
Bisoprolol Fumarate
2Y$3$10NANN
Bisoprolol Fumarate And Hydrochlorothiazide
1Y$1$8NANN
Blisovi 24 Fe
4Y41%43%41%NN
Blisovi Fe 1.5/30
4Y41%43%41%NN
Boostrix
3Y17%19%NANN
Bosulif
525%25%25%30/30YN
Braftovi
525%25%25%180/30YN
Breo Ellipta
3Y17%19%NA60/30NN
Brilinta
4Y41%43%41%60/30NN
Brimonidine Tartrate
4Y41%43%41%NN
Briviact
4Y41%43%41%600/30NN
Budesonide
4Y41%43%41%NN
Bumetanide
2Y$3$10NANN
Buprenorphine
3Y17%19%NAYN
Buprenorphine And Naloxone
2Y$3$10NA60/30NN
Buprenorphine Hcl
3Y17%19%NAYN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2Y$3$10NA90/30NN
Bupropion Hydrochloride
3Y17%19%NA30/30NN
Buspirone Hydrochloride
2Y$3$10NANN
Butorphanol Tartrate
4Y41%43%41%10/28NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S7126-022

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $480. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4430
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2022 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Q1 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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MedicareHelp.org is a privately-owned Non-governmental agency operated by Mark Spencer. The government website can be found at HealthCare.gov.

HealthCompare Insurance Services, HealthPlanOne, LLC, ClearMatch Medicare and Medicare Solutions does not offer every plan available in your area. Currently HealthCompare Insurance Services represent 18 organizations, which offers 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. HealthCompare Insurance Services, HealthPlanOne, LLC, ClearMatch Medicare and Medicare Solutions represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

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