Forms & Resources
The Summary of Benefits provides a summary of what the plan covers and what you pay.
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.
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
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.
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.
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 therapy requirements and the rules that apply to each drug.
Annual Notice of Change
The Annual Notice of Change includes any changes in coverage, costs, or service area that will be effective starting in January.
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.
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.
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. Get further instructions on how to appoint a representative.
For all coverage review requests other than formulary changes, this form should be used to initiate the coverage review process. Once complete, the form should be faxed to us (without a cover sheet) at 877-251-5896. You may also submit your coverage determination request online.
This form should be used to initiate an appeal of a previously declined coverage review request. Once complete, the form should be faxed to us (without a cover sheet) at 877-328-9660. You can also submit a coverage redetermination request form online.
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.