Mutual of Omaha Rx Premier (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Mutual of Omaha Rx Premier (PDP) by Omaha Health Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a 2023 Medicare Part-D in New Mexico plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Mutual of Omaha Rx Premier (PDP)(S7126-095) plan has a $505 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 $4660. 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 $4660 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" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Omaha Health Insurance Company 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 above the chart.



Plan Overview

Plan Name:Mutual of Omaha Rx Premier (PDP)
Plan ID: S7126-095
Formulary
Provider: Omaha Health Insurance Company
Plan Year:2023
Premium:$52.10
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:New Mexico
Similar Plan:S7126-096


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
M-m-r Ii
3Y$45$47NANN
Magnesium Sulfate
4Y45%47%45%NN
Malathion
4Y45%47%45%NN
Marplan
4Y45%47%45%NN
Matulane
525%25%25%NN
Meclizine Hydrochloride
2N$10$17NANN
Medroxyprogesterone Acetate
4Y45%47%45%NN
Mefloquine Hydrochloride
2N$10$17NANN
Megestrol Acetate
4Y45%47%45%YN
Mekinist
525%25%25%30/30YN
Mektovi
525%25%25%180/30YN
Memantine
4Y45%47%45%YN
Memantine Hydrochloride
4Y45%47%45%YN
Menactra
3Y$45$47NANN
Menquadfi
3Y$45$47NANN
Menveo
3Y$45$47NANN
Mercaptopurine
4Y45%47%45%NN
Meropenem
4Y45%47%45%NN
Mesalamine
4Y45%47%45%NN
Mesnex
4Y45%47%45%NN
Metformin Hydrochloride
1N$1$8NA60/30NN
Metformin Hydrochloride Oral Solution
4Y45%47%45%765/30NN
Methadone Hydrochloride
3Y$45$47NA120/30YN
Methazolamide
4Y45%47%45%NN
Methenamine Hippurate
4Y45%47%45%NN
Methimazole
2N$10$17NANN
Methotrexate
3Y$45$47NAYN
Methylphenidate Hydrochloride
4Y45%47%45%NN
Methylphenidate Hydrochloride (la)
4Y45%47%45%NN
Methylphenidate Hydrochloride Cd
3Y$45$47NANN
Methylprednisolone
2N$10$17NAYN
Metoclopramide
2N$10$17NANN
Metolazone
3Y$45$47NANN
Metoprolol Succinate
2N$10$17NANN
Metoprolol Tartrate
1N$1$8NANN
Metoprolol Tartrate And Hydrochlorothiazide
3Y$45$47NANN
Metronidazole
4Y45%47%45%NN
Metyrosine
525%25%25%YN
Mexiletine Hydrochloride
4Y45%47%45%NN
Micafungin
525%25%25%NN
Minocycline Hydrochloride
2N$10$17NANN
Minoxidil
2N$10$17NANN
Mirtazapine
3Y$45$47NANN
Molindone Hydrochloride
4Y45%47%45%NN
Mometasone Furoate
4Y45%47%45%34/30NN
Montelukast Sodium
4Y45%47%45%NN
Morphine Sulfate
3Y$45$47NA120/30YN
Movantik
3Y$45$47NA30/30NN
Moxifloxacin
3Y$45$47NANN
Mupirocin
2N$10$17NA44/30NN
Myalept
525%25%25%YN
Mycophenolate Mofetil
525%25%25%YN
Mycophenolic Acid
4Y45%47%45%YN
Myrbetriq
3Y$45$47NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S7126-095

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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 $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 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 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 plan's 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.

Last updated on
Source:CMS Formulary Data Q4 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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