ONDANSETRON HYDROCHLORIDE 4 mg/5mL Solution

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Pennsylvania and West Virginia	10 of 12	2–4	$5.00	10 of 10 plans
Michigan	10 of 12	3–4	—	10 of 10 plans
California	10 of 12	3–4	—	10 of 10 plans
New Jersey	9 of 12	3–4	—	8 of 9 plans
North Carolina	9 of 12	3–4	—	8 of 9 plans
South Carolina	9 of 11	3–4	—	9 of 9 plans
Alabama and Tennessee	9 of 12	3–4	—	8 of 9 plans
Illinois	9 of 12	3–4	—	8 of 9 plans
Arkansas	9 of 12	3–4	—	9 of 9 plans
Texas	9 of 12	3–4	—	8 of 9 plans
Kansas	9 of 12	3–4	—	7 of 9 plans
Connecticut, Massachusetts, Rhode Island and Vermont	8 of 11	2–4	$10.00	8 of 8 plans
New York	8 of 10	3–4	—	8 of 8 plans
Delaware, DC and Maryland	8 of 10	3–4	—	8 of 8 plans
Georgia	8 of 10	3–4	—	8 of 8 plans
Ohio	8 of 10	3–4	—	8 of 8 plans
Indiana and Kentucky	8 of 10	2–4	$10.00	8 of 8 plans
Wisconsin	8 of 10	2–4	$10.00	8 of 8 plans
Missouri	8 of 10	3–4	—	8 of 8 plans
Mississippi	8 of 10	3–4	—	8 of 8 plans
Louisiana	8 of 10	2–4	$10.00	8 of 8 plans
Oklahoma	8 of 11	3–4	—	7 of 8 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	8 of 11	2–4	$10.00	8 of 8 plans
New Mexico	8 of 11	3–4	—	7 of 8 plans
Colorado	8 of 10	3–4	—	8 of 8 plans
Arizona	8 of 10	3–4	—	8 of 8 plans
Nevada	8 of 10	3–4	—	8 of 8 plans
Oregon and Washington	8 of 10	3–4	—	8 of 8 plans
Idaho and Utah	8 of 10	2–4	$10.00	8 of 8 plans
Maine and New Hampshire	7 of 9	3–4	—	7 of 7 plans
Virginia	7 of 9	3–4	—	7 of 7 plans
Florida	7 of 10	3–4	—	6 of 7 plans
Alaska	7 of 9	3–4	—	7 of 7 plans
Hawaii	6 of 8	2–4	$10.00	6 of 6 plans
Puerto Rico	3 of 3	3–4	—	3 of 3 plans
American Samoa	1 of 1	4	—	1 of 1 plans
Guam	1 of 1	4	—	1 of 1 plans
Northern Mariana Islands	1 of 1	4	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	4	—	1 of 1 plans

Pennsylvania and West Virginia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1663	$1.509 units	Prior authorization Quantity limit 9 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.3189	—	Prior authorization
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.3189	—	Prior authorization
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2987	—	Prior authorization
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4719	$21.2445 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4738	$21.3245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.4333	$3.909 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$1.0244	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$0.4054	$3.659 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4709	$21.1945 units	Prior authorization Quantity limit 45 per 30 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.6121	—	Prior authorization
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2327	$2.099 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.1105	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.5407	$24.3345 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.5422	$24.4045 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.6542	$5.899 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$0.6323	$5.699 units	Prior authorization Quantity limit 9 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.3564	—	Prior authorization
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5399	$24.3045 units	Prior authorization Quantity limit 45 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	4Non-Preferred Drug	27%	27%	$0.3564	—	Prior authorization

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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2365	—	Prior authorization
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2444	$2.209 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.9446	—	Prior authorization
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.5009	$22.5445 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4442	$4.009 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4981	$22.4145 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$0.4176	$3.769 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4965	$22.3445 units	Prior authorization Quantity limit 45 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	4Non-Preferred Drug	49%	49%	$0.7340	$66.0690 units	Prior authorization Quantity limit 3 per 1 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	4Non-Preferred Drug	37%	37%	$0.7340	$66.0690 units	Prior authorization Quantity limit 3 per 1 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 Jersey — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$1.0664	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2570	$2.319 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4977	$22.4045 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.4978	$22.4045 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.8036	$7.239 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.8008	—	Prior authorization
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4977	$22.4045 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$0.7821	$7.049 units	Prior authorization Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$0.9721	—	None

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 — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2363	—	Prior authorization
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2301	$2.079 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4971	$22.3745 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.4982	$22.4245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4278	$3.859 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.9539	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4965	$22.3445 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$0.4009	$3.619 units	Prior authorization Quantity limit 9 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$1.1078	—	None

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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.9322	—	Prior authorization
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2355	$2.129 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.5308	$23.8945 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5369	$24.1645 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4244	$3.829 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.4072	$3.669 units	Prior authorization Quantity limit 9 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$0.3268	$14.7145 units	Prior authorization Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5274	$23.7345 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$1.3915	—	Prior authorization

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 — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.3556	—	Prior authorization
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2333	$2.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4878	$21.9545 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4929	$22.1845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4318	$3.899 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.0021	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4850	$21.8245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.3970	$3.579 units	Prior authorization Quantity limit 9 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$1.1605	—	None

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 — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.7882	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2329	$2.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.5000	$22.5045 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.5039	$22.6845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.4266	$3.849 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$0.4102	$3.699 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.3418	—	Prior authorization
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4978	$22.4045 units	Prior authorization Quantity limit 45 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.1323	—	None

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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7186	—	Prior authorization
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3128	$2.829 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6223	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4426	$19.9245 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4492	$20.2145 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4332	$3.909 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4390	$19.7545 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$0.3869	$3.489 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$0.8072	—	Prior authorization

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 — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.4720	—	Prior authorization
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2328	$2.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5053	$22.7445 units	Prior authorization Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.5004	$22.5245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4294	$3.869 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$1.1105	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.4155	$3.749 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4977	$22.4045 units	Prior authorization Quantity limit 45 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.0593	—	None

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 — 9 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2325	$2.099 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.9167	—	None
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.8575	—	Prior authorization
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4563	$20.5345 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.4571	$20.5745 units	Prior authorization Quantity limit 45 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$0.9755	—	None
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.5923	$5.339 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4558	$20.5145 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$0.5657	$5.099 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1179	$1.069 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.5094	$22.9245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.5081	$4.579 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.5143	$23.1445 units	Prior authorization Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5067	$22.8045 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$1.3394	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$0.4954	$4.469 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	4Non-Preferred Drug	35%	35%	$0.3739	—	Prior authorization

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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.1885	—	Prior authorization
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2347	$2.119 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.9061	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4718	$4.259 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.4995	$22.4845 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.5014	$22.5645 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$0.4479	$4.039 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4984	$22.4345 units	Prior authorization Quantity limit 45 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.3127	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2393	$2.159 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4812	$21.6545 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4829	$21.7345 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.0002	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.5262	$4.749 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.4968	$4.479 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4802	$21.6145 units	Prior authorization Quantity limit 45 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.6349	—	Prior authorization
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2390	$2.159 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4543	$20.4445 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.4563	$20.5345 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4326	$3.899 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4531	$20.3945 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.3887	$3.509 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5610	—	Prior authorization

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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.7671	—	Prior authorization
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2332	$2.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.4998	$22.4945 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5062	$22.7845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4268	$3.849 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.3635	—	Prior authorization
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4963	$22.3345 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.4047	$3.649 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1629	$1.479 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2916	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.5156	$23.2045 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5170	$23.2745 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$0.4504	$4.059 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.9272	—	Prior authorization
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5149	$23.1745 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.4196	$3.789 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1257	$1.139 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.4167	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.1210	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4825	$21.7145 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.4894	$22.0245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4261	$3.839 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4787	$21.5445 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.4029	$3.639 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0182	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2323	$2.099 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4652	$20.9345 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.4712	$21.2045 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.5644	$5.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.8431	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.5344	$4.819 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4619	$20.7945 units	Prior authorization Quantity limit 45 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$2.6153	—	Prior authorization
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2320	$2.099 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.5857	$26.3645 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.5948	$26.7745 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.7498	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$0.4222	$3.809 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5807	$26.1345 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.4115	$3.709 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1683	$1.519 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.6072	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.5352	$24.0845 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.5395	$24.2845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$0.4472	$4.029 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.1043	—	Prior authorization
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5328	$23.9845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.4218	$3.809 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$3.0623	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$0.6206	$27.9345 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.6311	$28.4045 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.4217	$3.809 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.6148	$27.6745 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$0.4129	$3.729 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$1.9687	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.2513	—	None

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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1284	$1.169 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$2.2340	—	Prior authorization
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.5938	$26.7245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.6444	$5.809 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5954	$26.7945 units	Prior authorization Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5929	$26.6845 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.4292	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.6310	$5.689 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2260	$2.039 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$1.9819	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4808	$21.6445 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$0.4290	$3.869 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.4992	$22.4645 units	Prior authorization Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4707	$21.1845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.4142	$3.739 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.4169	—	None

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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$2.4906	—	Prior authorization
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2309	$2.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.4970	$22.3645 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5147	$23.1645 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.8777	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4205	$3.789 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4871	$21.9245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$0.4172	$3.759 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$2.1306	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2195	$1.989 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$1.5163	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.5322	$23.9545 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5355	$24.1045 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4298	$3.879 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.4110	$3.709 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5305	$23.8745 units	Prior authorization Quantity limit 45 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.8738	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2457	$2.219 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.5517	$24.8345 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.5541	$24.9345 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4216	$3.799 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.3629	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.4128	$3.729 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.5504	$24.7745 units	Prior authorization Quantity limit 45 per 30 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 — 8 plans, 8 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	16%	16%	$1.0108	—	Prior authorization
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2352	$2.129 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.8055	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4632	$20.8445 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4662	$20.9845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.5052	$4.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4616	$20.7745 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$0.4693	$4.229 units	Prior authorization Quantity limit 9 per 30 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1951	$1.769 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.6863	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4556	$20.5045 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.4581	$20.6145 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4337	$3.909 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4543	$20.4445 units	Prior authorization Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5731	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.3870	$3.489 units	Prior authorization Quantity limit 9 per 30 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2786	$2.519 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5066	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4621	$20.7945 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.4621	$20.7945 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4801	$4.329 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$0.4384	$3.959 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4621	$20.7945 units	Prior authorization Quantity limit 45 per 30 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2256	$2.039 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4764	$21.4445 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.4795	$21.5845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4378	$3.949 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4747	$21.3645 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.4171	$3.759 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.8854	—	Prior authorization

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 — 7 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2338	$2.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4818	$21.6845 units	Prior authorization Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4795	$21.5845 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4375	$3.949 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4783	$21.5245 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.4030	$3.639 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6884	—	None

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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2315	$2.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$1.1126	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.4557	$20.5145 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4576	$20.5945 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4280	$3.859 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.4057	$3.659 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4547	$20.4645 units	Prior authorization Quantity limit 45 per 30 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.0983	$0.889 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4210	$3.799 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.4889	$22.0045 units	Prior authorization Quantity limit 45 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.5023	$22.6045 units	Prior authorization Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4815	$21.6745 units	Prior authorization Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.4154	$3.749 units	Prior authorization Quantity limit 9 per 30 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%	$2.0412	—	Prior authorization
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$1.2760	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.6994	$6.299 units	Prior authorization Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$0.7531	$6.789 units	Prior authorization Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$0.7531	$6.789 units	Prior authorization Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$0.3815	$3.439 units	Prior authorization Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$0.7531	$6.789 units	Prior authorization Quantity limit 9 per 30 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.

Coverage by region

Plan-by-plan detail