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

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

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.

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, 24 hours a day, seven days a week. TTY users: call 800-716-3231.

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

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 Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

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

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

Download a Coverage Determination Request Form. Submit a Medicare Part D coverage determination request form online.

Coverage Redetermination Request Form
The request for Medicare Prescription Drug Denial Form should be used to initiate an appeal to a previously declined coverage review request. Once complete, the form should be faxed to us (without a cover sheet) at 877-251-5896. Submit a Medicare Part D coverage redetermination request form online.

If you would like to appoint a person to file a grievance, request a coverage determination or exception or make an appeal on your behalf, you and the person accepting the appointment must fill out an Appointment of Representative Form (or a written equivalent) and submit it with the request. You can also get further instructions on how to appoint a Medicare Part D representative.

Mutual of Omaha Rx Transition Process
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary, but your ability to get it is limited. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary supply for a maximum 30 days at retail (unless you have a prescription written for fewer days) when you go to a network pharmacy within the first 90 days of the calendar year (or the first 90 days of your effective date if your coverage begins after the first of the year). After your first 30-day supply, we will not pay for these drugs. For additional information on our transition policy or if you are a resident of a long-term care facility, please refer to the plan's Medicare Part D Evidence of Coverage (10/11/2018).

Extra Help

You may be able to get Medicare Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Medicare Extra Help, call:

  • 1.800.MEDICARE (800-633-4227), 24 hours a day, seven days a week. TTY users, call 877-486-2048
  • The Social Security Office at 800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users, call 800-325-0778
  • Your State Medicaid Office

If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. However, it does not include any Medicare Part B premium you may have to pay.

Please note: If you have received assistance with your prescription drug costs from a charity and receive a refund, you should work directly with the charity to refund its portion.

Formulary

Brand-Name & Generic Drugs
Mutual of Omaha Rx covers both brand-name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. FDA-approved generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

Our Formularies
The Mutual of Omaha Rx formulary includes brand and generic drugs most commonly prescribed for seniors. Learn more about covered drugs.

60-Day Notice for Formulary Changes
We may periodically add or remove a drug, make changes to coverage rules on certain drugs, or change how much you pay for a drug. If we make any formulary change that limits your ability to fill prescriptions, we will notify you at least 60 days before the change is made. Note that if the FDA finds that a drug on the formulary is unsafe or if the drug's manufacturer removes the drug from the market, we immediately remove the drug from our formulary and then notify you of the change.

Coverage
Certain drugs may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

How to Request Dispute History

You may request information about the total number of grievances, appeals, and exceptions that have been filed with Mutual of Omaha Rx, as well as about the outcomes of these disputes. 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.

Medication Therapy Management Program

The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions and who take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health. ExpressScripts is performing this service on behalf of Mutual of Omaha Rx.

You must be eligible to qualify for the MTM program. Please see below for those details. If you qualify, you will be automatically enrolled into the program, and the service is provided at no additional cost to you. You may choose not to participate in the program, but it is recommended that you make use of this free service.

The MTM program is offered through a relationship between Mutual of Omaha Rx and SinfoníaRx. The MTM program is not considered a part of the plan’s benefit.

You may qualify for the MTM program if:

  1. You have three or more chronic health problems.

    These may include:

    • Asthma
    • Chronic Heart Failure (CHF)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Diabetes
    • End-Stage Renal Disease (ESRD)
    • High blood fat levels
    • High blood pressure
    • Osteoporosis
  2. You take seven or more daily medicines covered by Medicare Part D.
  3. You spend $3,967 or more per year on Medicare Part D-covered medications.

If you qualify for the MTM program, you will be contacted and have the chance to speak with a highly-trained pharmacist or a pharmacist intern who works under the direct guidance of a pharmacist. During that call, the pharmacist or pharmacy intern will complete a comprehensive review of your medicines and talk with you about:

  • Any questions or concerns about your prescription or over-the-counter medicines, such as drug safety and cost
  • Better understanding your medicines and how to take them
  • How to get the most benefit from your medicines

If you qualify for the MTM program, you will receive:

  • A welcome letter that tells you how to get started
  • A full medication review
    • You will have the chance to review your medicines each year with a highly trained pharmacist or a pharmacist intern working under the direct guidance of a pharmacist. This review will take about 20 to 30 minutes. During this call, any issues with your medicines will be discussed. The call can be scheduled at a convenient time for you.
    • After you complete the full medication review, a summary is mailed to you. The summary includes a medication action plan
 with space for you to make notes or write down any follow-up questions.
    • You also will be mailed a personal medication list that includes all of the medicines that you take and the reasons why you take them.
  • Ongoing targeted medication reviews
    • At least once every three months, your medicines will be reviewed, and you or your doctor will be contacted. Please inform us of any changes in your list of medicines. You may get a letter or a phone call for this review.

For information about the MTM program or to see if you qualify, 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.

If you would like a copy of a blank personal medication list, download the blank list here.

Note: The Medication Therapy Management Program is not considered a benefit.

Medigap

If you have a Medigap (Medicare Supplement Insurance) policy that includes prescription drug coverage, you must contact your Medigap issuer to let them know that you have enrolled in a Medicare prescription drug plan. If you decide to keep your current Medigap policy, your Medigap issuer will remove the prescription drug coverage portion of your policy and lower your premium. Call your Medigap issuer for details.

Part D Quality Assurance & Utilization Management

Utilization Management
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits for our plans to help us provide quality coverage to our members:

  • Prior authorization: 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.
  • Step Therapy: 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.
  • Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
  • Generic Substitution: When there is a generic version of a brand-name drug available, out network pharmacies will automatically give you the generic version unless your doctor has told us that you must take the brand-named drug.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the Drug Formulary. If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able to meet the additional restrictions or limits for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

Drug Utilization Review
We conduct drug utilization reviews for all our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are not safe or appropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking at the same time
  • Drug allergies

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Pharmacy Access

Pharmacy Network
As an Mutual of Omaha Rx member, you have access to over 28,000 network pharmacies nationally, including convenient home delivery service through the Express Scripts Pharmacy.℠

Out-of-Network Coverage
In most cases, your prescriptions are covered under this plan only if they are filled at a retail network pharmacy or through our home delivery pharmacy. Covered Medicare Part D drugs are available at out-of-network pharmacies under certain circumstances, such as illness while traveling outside the plan's service area where there is no retail network pharmacy. You may incur an additional cost for prescriptions filled at an out-of-network pharmacy. Please note that the pharmacies in our network now may change. For the most up-to-date information, visit our Medicare Part D pharmacy locator tool or 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.

Pharmacy Access & Participation
This plan has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. In most cases, your prescriptions are covered under this plan only if they are filled at a retail network pharmacy or through our home delivery pharmacy. We will fill prescriptions at out-of-network pharmacies under certain circumstances. Quantity limitations and restrictions may apply.

Long-term care and home infusion pharmacies may service a broad area. Therefore, you may need to look outside your immediate area for these types of providers.

Pharmacy List
To get current information about Mutual of Omaha Rx pharmacies in your area, visit our Medicare Part D pharmacy locator tool. Inclusion in this list does not guarantee that a pharmacy continues to participate in our plan.

Plan Ratings

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients, and customer service). You may use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or "Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans in your area. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Premiums

As a member of our plan, you pay a monthly plan premium. In addition, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party, even if the Medicare Part D premium is $0. View a listing of Medicare Part D premiums by state.

If you are assessed a Medicare Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium.

If you would like to change your premium payment method, 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. Please note: If you do choose to change your method of payment, it may take up to three months for this change to take effect, and you may continue to be billed via the original method until your change takes effect.

Privacy

This website is designed to provide access to online information regarding the Mutual of Omaha Rx Part D product offering. In connection with providing this information, there are times when we will ask for, or collect, personal information from you. As part of our commitment to honor your privacy, this policy will explain the approach we take in protecting and using the information that we gather from you on this website. For your ease and convenience, we make this notice available on every page of the website, identified as "Privacy," with a link to this notice.

Service Area

The service area for the Plus and Value Mutual of Omaha Rx plans include 48 states (excluding Florida and New York) and includes the District of Columbia. The Plus and Value plans ARE NOT available in Puerto Rico or the Virgin Islands.

Service Complaint

  • If you would like to make a complaint, or for process or status questions regarding a complaint related to issues such as quality of care, waiting time, or the Customer Service you receive, you may 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

  • You may write to us and send by mail to:
    Mutual of Omaha Rx

    Attn: Grievance Resolution Team

    P.O. Box 3610

    Dublin, OH 43016-0307

OR

  • You may also fax your complaint to 877-832-5749

If you need assistance or more information on filing a complaint, please call Customer Service toll free at the number listed above.

If you would like to submit feedback about your Medicare Part D prescription drug plan directly to Medicare, please complete their online form:

Please visit the Medicare.gov complaint link to file a grievance.

You may also contact them by phone at 1.800.MEDICARE (800-633-4227), 24 hours a day, seven days a week. TTY users, call 877-486-2048.

Need Help?

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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.

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