Prescription Drug Plan Rules and Guidelines

Medicare Part D Rules and Guidelines

Contract Renewal

The Centers for Medicare & Medicaid Services (CMS) must approve Mutual of Omaha Rx each year. A beneficiary can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and CMS renews its approval of the plan.

Contract Termination Notice

All Medicare prescription drug plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare prescription drug plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.

Contracting Statement

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

Eligibility Requirements

A Part D–eligible beneficiary is defined as:

Being entitled to Medicare benefits under Part A and/or enrolled in Part B
Having Part D eligibility in the CMS systems
Being a permanent resident in the geographic service area of the Part D plan
Being a U.S. citizen or lawfully present in the U.S.

Additional Enrollment Information

You may be enrolled in only one Medicare Part D plan at a time

Enrollment/Disenrollment Options

Initial Enrollment Period
When you reach age 65, you have a seven-month period to enroll in a Medicare Part D plan:

Three months before the month you turn 65
The month you turn 65
Three months after the month you turn 65

If you join during the three months before you turn 65, your coverage will start on the first day of your birthday month. If you join during or after your birthday month, your coverage will begin on the first day of the next month.

If you are under 65 and eligible for Medicare due to a disability, you can enroll in a Medicare Part D plan during the seven-month period that begins:

Three months before the 25th month of your disability
The 25th month of your disability
Three months after your 25th month of disability
During your Initial Enrollment Period when you turn 65

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.

Annual Enrollment Period
The Annual Enrollment Period runs from October 15 through December 7 each year. In general, enrollment is allowed only during the Annual Enrollment Period unless you recently became eligible for Medicare or qualify for a Special Enrollment Period. 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.

Special Enrollment Period
A Special Enrollment Period is when a person, under certain circumstances, may enroll in, or disenroll from, a Medicare prescription drug plan at times other than during the Annual Enrollment Period. Examples of such circumstances may include receiving benefits from both Medicare and Medicaid; changing living situations (such as moving out of state or into a long-term care facility); losing creditable prescription drug coverage from an employer or other plan sponsor; or losing coverage because a plan no longer offers Medicare prescription drug coverage. 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.

Late Enrollment Penalty
The late enrollment penalty is 1 percent of the national average premium for every month you were without Medicare Part D prescription drug coverage or other creditable prescription drug coverage following your Initial Enrollment Period. Or, the penalty can be charged if you had a break in creditable prescription drug coverage for 63 or more consecutive days. Creditable prescription drug coverage (for example, from an employer or union) means that it is expected to pay, on average, as much as Medicare's standard prescription drug coverage. You will pay this late enrollment penalty for as long as you have Medicare Part D coverage.

Voluntary Disenrollment
Members may disenroll from a prescription drug plan during one of the election periods by following these guidelines:

You can end your membership during the Annual Enrollment Period. This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year
You can end your membership by enrolling in another plan
In certain situations, you can end your membership during a Special Enrollment Period

For more information about Voluntary Disenrollment, 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. Or contact Medicare at 800-MEDICARE (800-633-4227). TTY users, call 877-486-2048, 24 hours a day, seven days a week.

Required Involuntary Disenrollment
A prescription drug plan organization must end your membership in the plan if any of the following situations occur:

If you do not stay continuously enrolled in Medicare Part A or Part B (or both)
If you move out of our service area for more than 12 months
If you become incarcerated (go to prison)
If you are not a United States citizen or lawfully present in the United States
If you lie about or withhold information about other insurance you have that provides prescription drug coverage
If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
If you continuously behave in a way that is disruptive and makes it difficult for us to provide care for you and other members of our plan (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
If you let someone else use your membership card to get prescription drugs
If you do not pay the plan premiums for two consecutive calendar months
If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan, and you will lose prescription drug coverage

For more information about Involuntary Disenrollment, 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.

Exceptions, Appeals & Transition Process

If you would like to request a coverage determination (such as an exception to the rules or restrictions on our plan's coverage of a drug) or if you would like to make an appeal for us to reconsider a coverage decision, you may:

Initial Clinical Coverage Reviews
Use this contact information if you need a coverage decision for a medication that is not on the formulary.

Call toll free 844-374-7377, 24 hours a day, seven days a week. TTY users: call 800-716-3231.

Mutual of Omaha Rx
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Administrative Coverage Reviews and Appeals
Use this contact information if you need a coverage decision about a restriction on a specific medication, want to request a lower cost-sharing amount, or if you need to file an appeal because your request was denied.

Call toll free 800-413-1328, Monday through Friday, 8 a.m. - 6 p.m., Central. TTY users: call 800-716-3231.

Mutual of Omaha Rx
Attn: Medicare Administrative Department
P.O. Box 66587
St. Louis, MO 63166-6587

Clinical Appeals
Use this contact information if you need to file an appeal if your coverage review is denied.

Call toll free 844-374-7377, Monday through Friday, 8 a.m. - 8 p.m., Central. TTY users: call 800-716-3231.

Mutual of Omaha Rx
Attn: Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588