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Made, please cross a line through the item. Initial and date. If more space is required, please attach additional page(s). Please use complete legal names. Example: Mary J. Smith. Do not use Mrs. John H. Smith PARTICIPANT INFORMATION (PLEASE PRINT) Full Name: (First) (Middle) Date of Birth: (Last) Soc. Sec. No.: (Date) Ex. (999-99-9999) DESIGNATION OF PRIMARY BENEFICIARY(IES) (PLEASE PRINT) If more than one beneficiary is designated, please indicate the percentage (%) each benefi.

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United of Omaha Life Insurance Company United of Omaha® offers a diversified portfolio of life insurance, fixed annuities, medicare supplement and other insurance and financial services products through Mutual of Omaha's agency sales force, group sales offices and independent agent networks.

Fill out the form on this page (or you can call 1-888-493-6902) to begin the claims process.

In addition to the online tool, providers can also use the self-service phone line at 800-927-9197 and follow the prompts given to receive member eligibility.

Mutual of Omaha - Express Scripts is the pharmacy benefit manager for Mutual of Omaha Rx and will be providing some services on behalf of Mutual of Omaha Rx. Mutual of Omaha - Mutual of Omaha Rx (PDP) is a prescription drug plan with a Medicare contract.

We offer affordable copays, $0 to $20, for a 30-day supply on most commonly prescribed drugs. Our Essential plan offers a $0 deductible on Tier 1 and our Premier plan offers a $0 deductible on Tiers 1 & 2. Our Premier plan offers a $0 deductible and a $25 copay for a 30-day supply at preferred pharmacies.

CVS preferred network, including: CVS, CVS-Target, Walmart, Kroger pharmacy, Safeway pharmacy, Sam's Club and regional Rx networks. *Other pharmacies are available in our network. Visit MutualofOmahaRx.com For a full list of our preferred and participating pharmacy network.

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

A standard decision deadline for medical care you requested is 14 days. For paying for medical care you already received, the deadline is 30 days after we receive your request.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232