Evidence of Coverage
(10/01/2023)

Evidencia de cobertura

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.

Fraud, Waste or Abuse

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.

Appointment of
Representative Form

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.

Online Medicare
Prescription Drug
Coverage Determination
Form

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.

Online Coverage
Redetermination
Request Form

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.

Prescription Drug
Claim Form

Medicamento con receta médica
Formulario de reclamación

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.

Home Delivery
Order Form

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.