Forms & Resources
Forms & Resources
Beginning Jan. 1, 2025, we will no longer offer Prescription Drug Plans. We're still committed to helping you with your other insurance needs.
Your 2024 coverage will continue through the end of the year. You must enroll in a new plan for 2025. You won’t automatically be placed in a new plan.
Watch your mailbox for an official letter for more details. For help finding a plan:
Enrollment Materials
Summary of Benefits
(10/01/2023)
The Summary of Benefits provides a summary of what the plan covers and what you pay.
Enrollment Form
(10/01/2023)
For Consumer Use Only
You may also use this form to join Mutual of Omaha Rx. Print our online enrollment form and then complete and mail it to:
Mutual of Omaha Rx (PDP)
P.O. Box 3625
Scranton, PA 18505
Each year, the Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Part D plans based on a 5-star rating system. CMS considers how well the plans perform in different categories, including customer service, patient safety, and member experience and satisfaction.
Currently, Mutual of Omaha is being evaluated and does not have a star rating. The official CMS Star Rating can be found at www.Medicare.gov.
The Multi-Language Insert is a document that contains information about free language interpreter services available to you.
Formulary
Rx Essential Drug Formulary
(10/03/2024)
Rx Premier Drug Formulary
(10/03/2024)
Rx Plus Drug Formulary
(10/03/2024)
Formulario de medicamentos Rx
Essential
(10/03/2024)
Formulario de medicamentos Rx
Premier
(10/03/2024)
Formulario de medicamentos Rx
Plus
(10/03/2024)
The formulary is a list of prescription drugs that is approved for coverage under Mutual of Omaha Rx. Be sure to select the one that applies to your plan option and learn more about our formulary.
Please note: The formulary for each plan option may change at any time. You will receive notice when necessary.
Formulary Change Notice
Rx Essential Formulary Change Notice
(10/01/2024)
Rx Premier Formulary Change Notice
(10/01/2024)
Rx Plus Formulary Change Notice
(10/01/2024)
Rx Essential Formulary Change Notice
(09/01/2024)
Rx Premier Formulary Change Notice
(09/01/2024)
Rx Plus Formulary Change Notice
(09/01/2024)
Rx Essential Formulary Change Notice
(08/01/2024)
Rx Premier Formulary Change Notice
(08/01/2024)
Rx Plus Formulary Change Notice
(08/01/2024)
Rx Essential Formulary Change Notice
(07/01/2024)
Rx Premier Formulary Change Notice
(07/01/2024)
Rx Plus Formulary Change Notice
(07/01/2024)
Rx Essential Formulary Change Notice
(06/01/2024)
Rx Premier Formulary Change Notice
(06/01/2024)
Rx Plus Formulary Change Notice
(06/01/2024)
Rx Essential Formulary Change Notice
(05/01/2024)
Rx Premier Formulary Change Notice
(05/01/2024)
Rx Plus Formulary Change Notice
(05/01/2024)
Rx Essential Formulary Change Notice
(04/01/2024)
Rx Premier Formulary Change Notice
(04/01/2024)
Rx Plus Formulary Change Notice
(04/01/2024)
Rx Essential Formulary Change Notice
(03/01/2024)
Rx Premier Formulary Change Notice
(03/01/2024)
Rx Plus Formulary Change Notice
(03/01/2024)
Rx Essential Formulary Change Notice
(02/01/2024)
Rx Premier Formulary Change Notice
(02/01/2024)
Rx Plus Formulary Change Notice
(02/01/2024)
The formulary change notice is a list of prescription drugs that are changing under Mutual of Omaha Rx. Be sure the list applies to your plan option and learn more about our formulary change notice.
Please note: This is a notice that the formulary has changed.
Prior Authorization
Rx Essential Prior Authorization
(10/03/2024)
Rx Premier Prior Authorization
(10/03/2024)
Rx Plus Prior Authorization
(10/03/2024)
We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. Use these documents to view the lists of drugs that have prior authorization and the rules that apply to each drug.
Step Therapy
Rx Essential Step Therapy
(05/06/2024)
Rx Premier Step Therapy
(05/06/2024)
Rx Plus Step Therapy
(10/03/2024)
In some cases, we require you to try certain drugs first to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Use these documents to view the lists of drugs that have step herapy requirements and the rules that apply to each drug.
Annual Notice of Change
Annual Notice of Changes
Rx Essential
(10/01/2023)
Aviso Anual de Cambios
Rx Essential
(10/01/2023)
Annual Notice of Changes
Rx Premier
(10/01/2023)
Aviso Anual de Cambios
Rx Premier
(10/01/2023)
Annual Notice of Changes
Rx Plus
(10/01/2023)
Aviso Anual de Cambios
Rx Plus
(10/01/2023)
The Annual Notice of Change includes any changes in coverage, costs, or service area that will be effective starting in January.
Evidence of Coverage
(10/01/2023)
The Evidence of Coverage provides details about the Mutual of Omaha Rx prescription drug plan. Note: If you were automatically enrolled in the plan by CMS, be sure to review the Evidence of Coverage Rider as well. See Chapter 7 for information about the grievance, coverage determination (including exceptions), and appeals processes.
This document explains what you can do to help us if you suspect Medicare Part D fraud, waste or abuse.
Monthly Premium Chart
(10/01/2023)
As a member of Mutual of Omaha Rx, you will pay a monthly premium in addition to any premiums you may pay for Medicare Part A and Part B. The premium amount varies by plan and region. Use this document to see the monthly premiums in your state.
Extra Help Monthly
Premium Chart
(10/01/2023)
Tabla de prima mensual de ayuda adicional
(10/01/2023)
If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium, annual deductible and drug costs will be lower. Use this document to see what your monthly premium would be if you qualify for Extra Help.
Once enrolled, if you would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on your behalf, you and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.
For all coverage review requests other than formulary changes, this form should be used to initiate the coverage review process. You may also submit your coverage determination request by mail or fax.
This form should be used to initiate an appeal of a previously declined coverage review request. You can also submit a coverage redetermination request form by mail or fax.
This form can be used to request reimbursement, for a covered prescription or vaccine, that you purchased without using your Medicare Part D member ID card.
If you would like to have your prescriptions delivered to your home by our Express Scripts mail order pharmacy, complete this form. Your doctor can also submit prescriptions by fax or electronically to the Express Scripts pharmacy.
Filing a Grievance or Complaint
Plan Forms
- Medication Therapy Management (MTM) Program Requirements
- Pre-Enrollment Checklist
- Lista de verificación de preinscripción
- HIPAA Notice
- Pharmacy directory
- To request a physical copy of a Pharmacy Directory please contact Customer Service at 855-864-6797 | TTY:800-716-3231
Need Help?
Have questions about our PDP plans? Call one of our agents today.
If you have any questions, please contact Mutual of Omaha Rx at 855-864-6797. Customer Service is available 24 hours a day, 7 days a week. TTY users should call 800-716-3231.