MOUNJARO 7.5 mg/.5mL Injection, Solution (Tirzepatide) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	3–6	$11.00	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	3–6	$11.00	12 of 12 plans
North Carolina	12 of 12	3–6	$11.00	12 of 12 plans
Alabama and Tennessee	12 of 12	3–6	$11.00	12 of 12 plans
Michigan	12 of 12	3–6	$11.00	12 of 12 plans
Illinois	12 of 12	3–6	$11.00	12 of 12 plans
Arkansas	12 of 12	3–6	$11.00	12 of 12 plans
Texas	12 of 12	3–6	$11.00	12 of 12 plans
Kansas	12 of 12	3–6	$11.00	12 of 12 plans
California	12 of 12	3–6	$11.00	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	3–6	$11.00	11 of 11 plans
South Carolina	11 of 11	3–6	$11.00	11 of 11 plans
Oklahoma	11 of 11	3–6	$11.00	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	3–6	$11.00	11 of 11 plans
New Mexico	11 of 11	3–6	$11.00	11 of 11 plans
New York	10 of 10	3–6	$11.00	10 of 10 plans
Delaware, DC and Maryland	10 of 10	3–6	$11.00	10 of 10 plans
Georgia	10 of 10	3–6	$11.00	10 of 10 plans
Florida	10 of 10	3–6	$11.00	10 of 10 plans
Ohio	10 of 10	3–6	$11.00	10 of 10 plans
Indiana and Kentucky	10 of 10	3–6	$11.00	10 of 10 plans
Wisconsin	10 of 10	3–6	$11.00	10 of 10 plans
Missouri	10 of 10	3–6	$11.00	10 of 10 plans
Mississippi	10 of 10	3–6	$11.00	10 of 10 plans
Louisiana	10 of 10	3–6	$11.00	10 of 10 plans
Colorado	10 of 10	3–6	$11.00	10 of 10 plans
Arizona	10 of 10	3–6	$11.00	10 of 10 plans
Nevada	10 of 10	3–6	$11.00	10 of 10 plans
Oregon and Washington	10 of 10	3–6	$11.00	10 of 10 plans
Idaho and Utah	10 of 10	3–6	$11.00	10 of 10 plans
Maine and New Hampshire	9 of 9	3–6	$11.00	9 of 9 plans
Virginia	9 of 9	3–6	$11.00	9 of 9 plans
Alaska	9 of 9	3–6	$11.00	9 of 9 plans
Hawaii	8 of 8	3–6	$11.00	8 of 8 plans
Puerto Rico	3 of 3	3	—	3 of 3 plans
American Samoa	1 of 1	3	—	1 of 1 plans
Guam	1 of 1	3	—	1 of 1 plans
Northern Mariana Islands	1 of 1	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	1 of 1 plans

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$532.5506	$1,065.102 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$505.4215	$1,010.842 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$532.5506	$1,065.102 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$521.9479	$1,043.902 units	Prior authorization Quantity limit 2 per 28 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$547.1512	$1,094.302 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$565.6912	$1,131.382 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$521.9750	$1,043.952 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$532.5506	$1,065.102 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$565.6912	$1,131.382 units	Prior authorization Quantity limit 2 per 28 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$547.1512	$1,094.302 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5136	$1,081.032 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$505.4215	$1,010.842 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$533.3449	$1,066.692 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$509.7859	$1,019.572 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$533.3449	$1,066.692 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$540.5478	$1,081.102 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$564.4572	$1,128.912 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$525.1866	$1,050.372 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$525.2794	$1,050.562 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$564.4572	$1,128.912 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$533.3449	$1,066.692 units	Prior authorization Quantity limit 2 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$525.8986	$1,051.802 units	Prior authorization Quantity limit 2 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$524.8338	$1,049.672 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$509.7859	$1,019.572 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$511.9168	$1,023.832 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.7504	$1,069.502 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.7504	$1,069.502 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$569.9869	$1,139.972 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$529.8571	$1,059.712 units	Prior authorization Quantity limit 2 per 28 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$553.1965	$1,106.392 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$530.5681	$1,061.142 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.7504	$1,069.502 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$569.9869	$1,139.972 units	Prior authorization Quantity limit 2 per 28 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$553.1965	$1,106.392 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5689	$1,081.142 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$511.9168	$1,023.832 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$533.8805	$1,067.762 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$513.4532	$1,026.912 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$533.8805	$1,067.762 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$569.9588	$1,139.922 units	Prior authorization Quantity limit 2 per 28 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$553.0319	$1,106.062 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$528.1230	$1,056.252 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$529.5499	$1,059.102 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$533.8805	$1,067.762 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$569.9588	$1,139.922 units	Prior authorization Quantity limit 2 per 28 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	3Preferred Brand	$47.00	$94.00	$553.0319	$1,106.062 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.6577	$1,081.322 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$513.4532	$1,026.912 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$510.8787	$1,021.762 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$524.2482	$1,048.502 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.5655	$1,069.132 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.5655	$1,069.132 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$566.5801	$1,133.162 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$523.3357	$1,046.672 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$566.5801	$1,133.162 units	Prior authorization Quantity limit 2 per 28 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$533.2467	$1,066.492 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.5655	$1,069.132 units	Prior authorization Quantity limit 2 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$533.2467	$1,066.492 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5498	$1,081.102 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$510.8787	$1,021.762 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$513.3235	$1,026.652 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$536.7151	$1,073.432 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$536.7151	$1,073.432 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$572.9516	$1,145.902 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$531.5372	$1,063.072 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$551.7650	$1,103.532 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$572.9516	$1,145.902 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$531.9045	$1,063.812 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$536.7151	$1,073.432 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$543.5736	$1,087.152 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.6358	$1,081.272 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$513.3235	$1,026.652 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$512.4332	$1,024.872 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$523.9375	$1,047.882 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$531.5685	$1,063.142 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$531.5685	$1,063.142 units	Prior authorization Quantity limit 2 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$540.5576	$1,081.122 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$523.1375	$1,046.282 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$571.1584	$1,142.322 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$531.5685	$1,063.142 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$571.1584	$1,142.322 units	Prior authorization Quantity limit 2 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$540.5576	$1,081.122 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.1100	$1,082.222 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$512.4332	$1,024.872 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$512.0771	$1,024.152 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$532.3758	$1,064.752 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$532.3758	$1,064.752 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$527.1492	$1,054.302 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$569.8103	$1,139.622 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$555.7538	$1,111.512 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$527.3041	$1,054.612 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$569.8103	$1,139.622 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$532.3758	$1,064.752 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$545.0770	$1,090.152 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.6240	$1,081.252 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$512.0771	$1,024.152 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$553.7408	$1,107.482 units	Prior authorization Quantity limit 2 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$553.3925	$1,106.792 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$533.3775	$1,066.762 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$522.6651	$1,045.332 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.7111	$1,069.422 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.7111	$1,069.422 units	Prior authorization Quantity limit 2 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$553.3925	$1,106.792 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$570.2584	$1,140.522 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.7111	$1,069.422 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$570.2584	$1,140.522 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$542.9026	$1,085.812 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$522.6651	$1,045.332 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

California — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$525.7713	$1,051.542 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$509.3331	$1,018.672 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$525.8307	$1,051.662 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$533.6576	$1,067.322 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$563.6952	$1,127.392 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$533.6576	$1,067.322 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$563.6952	$1,127.392 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$533.6576	$1,067.322 units	Prior authorization Quantity limit 2 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$543.9116	$1,087.822 units	Prior authorization Quantity limit 2 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$543.9116	$1,087.822 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5516	$1,081.102 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$509.3331	$1,018.672 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Connecticut, Massachusetts, Rhode Island and Vermont — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.5838	$1,069.172 units	Prior authorization Quantity limit 2 per 28 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$530.7972	$1,061.592 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$507.5291	$1,015.062 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$540.5253	$1,081.052 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$565.2534	$1,130.512 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$534.5838	$1,069.172 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.5838	$1,069.172 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$527.4013	$1,054.802 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$565.2534	$1,130.512 units	Prior authorization Quantity limit 2 per 28 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$530.7972	$1,061.592 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$507.5291	$1,015.062 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$510.5820	$1,021.162 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$535.3805	$1,070.762 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$535.3805	$1,070.762 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$528.6885	$1,057.382 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$567.2230	$1,134.452 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$567.2230	$1,134.452 units	Prior authorization Quantity limit 2 per 28 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$535.0345	$1,070.072 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$535.3805	$1,070.762 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$529.8430	$1,059.692 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5659	$1,081.132 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$510.5820	$1,021.162 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$548.1027	$1,096.212 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$533.0411	$1,066.082 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$516.7577	$1,033.522 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$533.0411	$1,066.082 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$533.3249	$1,066.652 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$572.4619	$1,144.922 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$533.0411	$1,066.082 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$572.4619	$1,144.922 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$533.3143	$1,066.632 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$549.0401	$1,098.082 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$516.7577	$1,033.522 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$533.5755	$1,067.152 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$567.3086	$1,134.622 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$520.8663	$1,041.732 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$533.5755	$1,067.152 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$541.8444	$1,083.692 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$524.1934	$1,048.392 units	Prior authorization Quantity limit 2 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$557.6850	$1,115.372 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$533.5755	$1,067.152 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$524.5863	$1,049.172 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$567.3086	$1,134.622 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$520.8663	$1,041.732 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

New Mexico — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$517.3069	$1,034.612 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$532.9476	$1,065.902 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.9781	$1,069.962 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$572.8256	$1,145.652 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.9781	$1,069.962 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.9781	$1,069.962 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$572.8256	$1,145.652 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	3Preferred Brand	14%	14%	$547.1541	$1,094.312 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$559.6815	$1,119.362 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.0992	$1,082.202 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$517.3069	$1,034.612 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$520.4696	$1,040.942 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$505.4568	$1,010.912 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$520.5757	$1,041.152 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$564.3145	$1,128.632 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$531.8361	$1,063.672 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$531.8361	$1,063.672 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$564.3145	$1,128.632 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$531.8361	$1,063.672 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.6071	$1,081.212 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$505.4568	$1,010.912 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Delaware, DC and Maryland — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.0258	$1,068.052 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.0258	$1,068.052 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$510.0060	$1,020.012 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$527.5614	$1,055.122 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$566.2849	$1,132.572 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$527.3916	$1,054.782 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$566.2849	$1,132.572 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.0258	$1,068.052 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5274	$1,081.052 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$510.0060	$1,020.012 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$514.8248	$1,029.652 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$535.2151	$1,070.432 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$535.2151	$1,070.432 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$527.0225	$1,054.052 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$568.4006	$1,136.802 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$535.2151	$1,070.432 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$568.4006	$1,136.802 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$529.1895	$1,058.382 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.0944	$1,082.192 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$514.8248	$1,029.652 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$510.4276	$1,020.862 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$536.3700	$1,072.742 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$536.3700	$1,072.742 units	Prior authorization Quantity limit 2 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$556.8097	$1,113.622 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$568.4848	$1,136.972 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$536.3700	$1,072.742 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$568.4848	$1,136.972 units	Prior authorization Quantity limit 2 per 28 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$556.8097	$1,113.622 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5559	$1,081.112 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$510.4276	$1,020.862 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.2878	$1,068.582 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$515.8755	$1,031.752 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.2878	$1,068.582 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$527.2746	$1,054.552 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$561.2221	$1,122.442 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$528.5360	$1,057.072 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.2878	$1,068.582 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$561.2221	$1,122.442 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5598	$1,081.122 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$515.8755	$1,031.752 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Indiana and Kentucky — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$535.4258	$1,070.852 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$516.4476	$1,032.902 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$535.4258	$1,070.852 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$540.5941	$1,081.192 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$529.0539	$1,058.112 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$568.3826	$1,136.772 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$530.2702	$1,060.542 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$535.4258	$1,070.852 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$568.3826	$1,136.772 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$516.4476	$1,032.902 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Wisconsin — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$513.0724	$1,026.142 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$526.0869	$1,052.172 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$531.5372	$1,063.072 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$531.5372	$1,063.072 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$573.2419	$1,146.482 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$541.0067	$1,082.012 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$525.6158	$1,051.232 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$531.5372	$1,063.072 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$573.2419	$1,146.482 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$513.0724	$1,026.142 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Missouri — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$514.5831	$1,029.172 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.1516	$1,068.302 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.1516	$1,068.302 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$529.9888	$1,059.982 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$572.5730	$1,145.152 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$530.1046	$1,060.212 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$572.5730	$1,145.152 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.1516	$1,068.302 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.3967	$1,082.792 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$514.5831	$1,029.172 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$515.2734	$1,030.552 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$531.8388	$1,063.682 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$531.8388	$1,063.682 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$527.0368	$1,054.072 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$526.2209	$1,052.442 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$570.8598	$1,141.722 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$531.8388	$1,063.682 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$570.8598	$1,141.722 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.9587	$1,081.922 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$515.2734	$1,030.552 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Louisiana — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$532.9987	$1,066.002 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$509.6181	$1,019.242 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$532.9987	$1,066.002 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$572.6109	$1,145.222 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$540.7511	$1,081.502 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$525.6653	$1,051.332 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$525.5845	$1,051.172 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$532.9987	$1,066.002 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$572.6109	$1,145.222 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$509.6181	$1,019.242 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Colorado — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$535.1290	$1,070.262 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$524.5502	$1,049.102 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$535.1290	$1,070.262 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$533.2227	$1,066.452 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$531.0069	$1,062.012 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$571.7106	$1,143.422 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$535.1290	$1,070.262 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$571.7106	$1,143.422 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.3017	$1,082.602 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$524.5502	$1,049.102 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Arizona — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$518.9724	$1,037.942 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$534.6436	$1,069.292 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$535.8944	$1,071.792 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$535.8944	$1,071.792 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$567.9684	$1,135.942 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$533.8598	$1,067.722 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$567.9684	$1,135.942 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$535.8944	$1,071.792 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5757	$1,081.152 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$518.9724	$1,037.942 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$536.0181	$1,072.042 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$515.0882	$1,030.182 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$536.0181	$1,072.042 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$530.3596	$1,060.722 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$568.8475	$1,137.692 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$531.4378	$1,062.882 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$568.8475	$1,137.692 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$536.0181	$1,072.042 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5249	$1,081.052 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$515.0882	$1,030.182 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$518.7489	$1,037.502 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$526.7509	$1,053.502 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$532.8443	$1,065.692 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$532.8443	$1,065.692 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$567.7083	$1,135.422 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$525.9557	$1,051.912 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$532.8443	$1,065.692 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$567.7083	$1,135.422 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.0731	$1,082.152 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$518.7489	$1,037.502 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Idaho and Utah — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$531.7737	$1,063.552 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$531.7737	$1,063.552 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$515.6624	$1,031.322 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$540.7193	$1,081.442 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$520.3916	$1,040.782 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$567.8597	$1,135.722 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$531.7737	$1,063.552 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$522.1065	$1,044.212 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$567.8597	$1,135.722 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$515.6624	$1,031.322 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Maine and New Hampshire — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$514.2650	$1,028.532 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$530.5581	$1,061.122 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$534.3846	$1,068.772 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$534.3846	$1,068.772 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$569.6782	$1,139.362 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$569.6782	$1,139.362 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$534.3846	$1,068.772 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5798	$1,081.162 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$514.2650	$1,028.532 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$512.5261	$1,025.052 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$535.5423	$1,071.082 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$535.5423	$1,071.082 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$567.8288	$1,135.662 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$535.5423	$1,071.082 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$567.8288	$1,135.662 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$530.1003	$1,060.202 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5746	$1,081.152 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$512.5261	$1,025.052 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$529.5055	$1,059.012 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$533.0690	$1,066.142 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	19%	$536.4271	$1,072.852 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$536.4271	$1,072.852 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$566.6417	$1,133.282 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$566.6417	$1,133.282 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$536.4271	$1,072.852 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$541.7839	$1,083.572 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$529.5055	$1,059.012 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$565.1302	$1,130.262 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$537.6497	$1,075.302 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$542.8600	$1,085.722 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$509.1503	$1,018.302 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$537.6497	$1,075.302 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$537.6497	$1,075.302 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$565.1302	$1,130.262 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$509.1503	$1,018.302 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$526.0354	$1,052.072 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$526.0348	$1,052.072 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$562.8190	$1,125.642 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$580.7532	$1,161.512 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$563.8687	$1,127.742 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$580.7532	$1,161.512 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

U.S. Virgin Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$642.0448	$1,284.092 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

MOUNJARO 7.5 mg/.5mL Injection, Solution

Coverage by region

Plan-by-plan detail