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Offered by Mutual of Omaha Rx

Cost Calculator
Answer a few simple questions and we'll help estimate your annual medication costs
and find which of our Prescription Drug Plans best fit your needs.

Your Recommendation is
Mutual of Omaha RX Premier Plan

See how the plans compare:

YOUR RECOMMENDATION

Mutual of Omaha RX Mutual of Omaha RX

Premier Plan Plus Plan
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Premium $35.00 /month Premium $92.80 /month
Deductible $0 Tier 1 & 2 | $480 Deductible $480 Tiers 1 - 5
Tiers 3 - 5

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Not eligible for special

Prescription
Not eligible for special Drug Plan
assistance
assistance Pharmacy Selection Edit
CVS Pharmacy #01383
Pharmacy Selection Edit
7205 Little River Tpk, Annandale,
CVS Pharmacy #01383
VA 22003
7205 Little River Tpk, Annandale,
VA 22003
Medications Based on a 30 Edit
Day Supply
Medications Based on a 30 Edit
Restasis NOT COVERED
Day Supply
Retail Supply $28,582.08/year
Restasis
Mail Order Refill $28,575.52/year
Retail Supply $2,273.43/year
Mail Order Refill $2,163.79/year

Estimated Total Annual Estimated Total Annual

Costs Costs
(Premium + Your Costs) (Premium + Your Costs)

Mutual of Omaha RX
Mutual of Omaha RX

Premier Plan Plus Plan

Total for Retail 30 Day Supplies Total for Retail 30 Day Supplies

$2,693.43 $29,695.68
Total for Mail Order Refills Total for Mail Order Refills

$2,583.79 $29,689.12

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Prescription Drug Plan

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Here you can find answers to commonly asked questions, everything from the
basics all the way to how to switch plans.

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about Medicare. Choose from different journey entry points, whether you’re a
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Mutual of Omaha Rx | 3300 Mutual of Omaha Plaza | Omaha NE 68175

Mailing Address: Mutual of Omaha Rx | P.O. Box 3625 | Scranton PA 18505

Contact
Mutual of Omaha Rx (PDP) is a prescription drug Us a Medicare contract. Enrollment in the
plan with
Mutual of Omaha Rx plan depends on contract renewal.

Other Pharmacies/Physicians/Providers are available in our network.

This information is not a complete description of benefits. Call 833-530-2714/TTY 800-716-3231

for more information.

Mutual of Omaha Rx’s pharmacy network includes limited lower-cost, preferred pharmacies in rural Menu
areas in Alaska. The lower costs advertised in our plan materials for these pharmacies may not be

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available at the pharmacy you use. For up-to-date information about our network pharmacies,
Prescription
including whether there are any lower-cost preferredDrug Plan in your area, please call Customer
pharmacies
Service at 855-864-6797/TTY 800-716-3231, or consult the online pharmacy directory at
MutualofOmahaRx.com/2022network.

La red de farmacias de Mutual of Omaha Rx incluye una cantidad limitada de farmacias preferidas con
costos más bajos en áreas rurales de Alaska. Los costos más bajos que se publican en los materiales de
nuestros planes para estas farmacias pueden no estar disponibles en su farmacia. Para obtener
información actualizada acerca de las farmacias de nuestra red, incluso si hay farmacias preferidas con
costos más bajos en su área, llame al Servicio al cliente al 855-864-6797/TTY 800-716-3231, o consulte el
directorio de farmacias en línea en MutualofOmahaRx.com/2022network.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive
notice when necessary.

Medicare beneficiaries may also enroll in Mutual of Omaha Rx Premier, or Mutual of Omaha Rx Plus
plans through the CMS Medicare Online Enrollment Center located at www.medicare.gov .

Every year, Medicare evaluates plans based on a 5-star rating system. The official CMS Star Rating can
be found at www.medicare.gov .

Need Help?

If you have any questions, please contact Mutual of Omaha Rx (PDP) at 855-864-6797. Customer Service
is available 24 hours a day, 7 days a week. TTY users should call 800-716-3231.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
855-864-6797/TTY 800-716-3231.

Non-discrimination Notice

Mutual of Omaha Rx complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability or sex.

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