IBRANCE 125 mg Capsule (Palbociclib) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	5	—	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	5	—	12 of 12 plans
North Carolina	12 of 12	5	—	12 of 12 plans
Alabama and Tennessee	12 of 12	5	—	12 of 12 plans
Michigan	12 of 12	5	—	12 of 12 plans
Illinois	12 of 12	5	—	12 of 12 plans
Arkansas	12 of 12	5	—	12 of 12 plans
Texas	12 of 12	5	—	12 of 12 plans
Kansas	12 of 12	5	—	12 of 12 plans
California	12 of 12	5	—	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	5	—	11 of 11 plans
South Carolina	11 of 11	5	—	11 of 11 plans
Oklahoma	11 of 11	5	—	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	5	—	11 of 11 plans
New Mexico	11 of 11	5	—	11 of 11 plans
New York	10 of 10	5	—	10 of 10 plans
Delaware, DC and Maryland	10 of 10	5	—	10 of 10 plans
Georgia	10 of 10	5	—	10 of 10 plans
Florida	10 of 10	5	—	10 of 10 plans
Ohio	10 of 10	5	—	10 of 10 plans
Indiana and Kentucky	10 of 10	5	—	10 of 10 plans
Wisconsin	10 of 10	5	—	10 of 10 plans
Missouri	10 of 10	5	—	10 of 10 plans
Mississippi	10 of 10	5	—	10 of 10 plans
Louisiana	10 of 10	5	—	10 of 10 plans
Colorado	10 of 10	5	—	10 of 10 plans
Arizona	10 of 10	5	—	10 of 10 plans
Nevada	10 of 10	5	—	10 of 10 plans
Oregon and Washington	10 of 10	5	—	10 of 10 plans
Idaho and Utah	10 of 10	5	—	10 of 10 plans
Maine and New Hampshire	9 of 9	5	—	9 of 9 plans
Virginia	9 of 9	5	—	9 of 9 plans
Alaska	9 of 9	5	—	9 of 9 plans
Hawaii	8 of 8	5	—	8 of 8 plans
Puerto Rico	3 of 3	5	—	3 of 3 plans
American Samoa	1 of 1	5	—	1 of 1 plans
Guam	1 of 1	5	—	1 of 1 plans
Northern Mariana Islands	1 of 1	5	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	5	—	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	5Specialty Tier	25%	—	$610.2646	$13,425.8222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$662.2762	$14,570.0822 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$662.2762	$14,570.0822 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$610.2646	$13,425.8222 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$607.5338	$13,365.7422 units	Prior authorization Quantity limit 21 per 28 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$611.7689	$13,458.9222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$650.1022	$19,503.0730 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$607.1562	$13,357.4422 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$610.2646	$13,425.8222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$650.1022	$19,503.0730 units	Prior authorization Quantity limit 21 per 21 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$611.7689	$13,458.9222 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$614.5148	$13,519.3322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$614.5148	$13,519.3322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.4807	$19,334.4230 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.4807	$19,334.4230 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$614.5148	$13,519.3322 units	Prior authorization Quantity limit 21 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 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 Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$571.5288	$12,573.6322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$571.5288	$12,573.6322 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$616.9386	$13,572.6522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$616.9386	$13,572.6522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$571.4709	$12,572.3622 units	Prior authorization Quantity limit 21 per 28 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$631.2054	$13,886.5222 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$571.4709	$12,572.3622 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$616.9386	$13,572.6522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$631.2054	$13,886.5222 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$610.2872	$13,426.3222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$588.8962	$12,955.7222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$588.8962	$12,955.7222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$610.2872	$13,426.3222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.2309	$19,446.9330 units	Prior authorization Quantity limit 21 per 21 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$635.5068	$13,981.1522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$575.8107	$12,667.8422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$575.7335	$12,666.1422 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$610.2872	$13,426.3222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$648.2309	$19,446.9330 units	Prior authorization Quantity limit 21 per 21 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$635.5068	$13,981.1522 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$571.8007	$12,579.6222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$571.8007	$12,579.6222 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.8509	$12,536.7222 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$606.2405	$13,337.2922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$606.2405	$13,337.2922 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$639.1437	$19,174.3130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$570.2343	$12,545.1522 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$639.1437	$19,174.3130 units	Prior authorization Quantity limit 21 per 21 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$616.0173	—	Prior authorization
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$606.2405	$13,337.2922 units	Prior authorization Quantity limit 21 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$616.0173	—	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.

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	5Specialty Tier	25%	—	$639.1730	$14,061.8122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$639.1730	$14,061.8122 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$617.2230	$13,578.9122 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$617.2230	$13,578.9122 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$661.0511	$19,831.5330 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$594.4252	$13,077.3522 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$636.2867	$13,998.3122 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$661.0511	$19,831.5330 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$594.1175	$13,070.5822 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$617.2230	$13,578.9122 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$636.2867	$13,998.3122 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$602.4100	$13,253.0222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$602.4100	$13,253.0222 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$601.6300	$13,235.8622 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$624.7931	$13,745.4522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$601.6300	$13,235.8622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$633.2884	$13,932.3422 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$624.7931	$13,745.4522 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$596.4238	$13,121.3222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$596.4238	$13,121.3222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$612.4318	$13,473.5022 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$612.4318	$13,473.5022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$578.1100	$12,718.4222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$647.8217	$19,434.6530 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.6848	$14,271.0722 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$629.9884	$13,859.7422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$578.0253	$12,716.5622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$647.8217	$19,434.6530 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$612.4318	$13,473.5022 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$629.4806	$13,848.5722 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$646.7692	$14,228.9222 units	Prior authorization Quantity limit 21 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.0762	$14,257.6822 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$613.3881	$13,494.5422 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$618.9294	$13,616.4522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$618.9294	$13,616.4522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$645.8517	$14,208.7422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$645.8517	$14,208.7422 units	Prior authorization Quantity limit 21 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$648.0762	$14,257.6822 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$669.5868	$20,087.6030 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$645.8517	$14,208.7422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$669.5868	$20,087.6030 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$593.6025	$13,059.2522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$647.1994	$14,238.3922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$647.1994	$14,238.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$593.9697	$13,067.3322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$619.1844	$13,622.0622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$659.9498	$19,798.4930 units	Prior authorization Quantity limit 21 per 21 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$619.1844	$13,622.0622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$659.9498	$19,798.4930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$619.1844	$13,622.0622 units	Prior authorization Quantity limit 21 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$627.8292	$13,812.2422 units	Prior authorization Quantity limit 21 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$627.8292	$13,812.2422 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$610.1159	$13,422.5522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$618.1778	$13,599.9122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$610.1159	$13,422.5522 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$610.1159	$13,422.5522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$618.1778	$13,599.9122 units	Prior authorization Quantity limit 21 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 Value Script (PDP)$4.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.7741	$12,535.0322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.7741	$12,535.0322 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.7559	$12,534.6322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$638.2088	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.7559	$12,534.6322 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$630.7297	$13,876.0522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$568.7837	$12,513.2422 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$568.7837	$12,513.2422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$568.3110	$12,502.8422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$568.3110	$12,502.8422 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$625.0190	$13,750.4222 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$606.8867	$13,351.5122 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$570.4840	$12,550.6522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$570.4840	$12,550.6522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$606.8867	$13,351.5122 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$575.2473	$12,655.4422 units	Prior authorization Quantity limit 21 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$627.5804	$13,806.7722 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$606.8867	$13,351.5122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$575.2473	$12,655.4422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$568.1667	$12,499.6722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$568.1667	$12,499.6722 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$568.1667	$12,499.6722 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$590.8525	$12,998.7522 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$590.8525	$12,998.7522 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$584.4983	$12,858.9622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$598.5590	$13,168.3022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$598.5590	$13,168.3022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$584.5411	$12,859.9022 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$646.6577	$19,399.7330 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$611.7419	$13,458.3222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$611.7419	$13,458.3222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$646.6577	$19,399.7330 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$611.7419	$13,458.3222 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$617.9299	$13,594.4622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$617.9299	$13,594.4622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$624.1983	$13,732.3622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$624.1983	$13,732.3622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$589.6347	$12,971.9622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$646.3835	$19,391.5130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$589.8699	$12,977.1422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$646.3835	$19,391.5130 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$617.9299	$13,594.4622 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$598.1466	$13,159.2322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$598.1466	$13,159.2322 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$607.9992	$13,375.9822 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$607.9992	$13,375.9822 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$583.3977	$12,834.7522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$646.7471	$19,402.4130 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$607.9992	$13,375.9822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$646.7471	$19,402.4130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$583.2973	$12,832.5422 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$594.9234	$13,088.3122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$594.9234	$13,088.3122 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$611.7998	$13,459.6022 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$611.7998	$13,459.6022 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$632.5674	$13,916.4822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$646.8143	$19,404.4330 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$611.7998	$13,459.6022 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$646.8143	$19,404.4330 units	Prior authorization Quantity limit 21 per 21 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$632.5674	$13,916.4822 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$617.5522	$13,586.1522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$577.4179	$12,703.1922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$577.4179	$12,703.1922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$617.5522	$13,586.1522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$577.2293	$12,699.0422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$577.2293	$12,699.0422 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$617.5522	$13,586.1522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$615.2719	$13,535.9822 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.4464	$13,297.8222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.4464	$13,297.8222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$615.2719	$13,535.9822 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.5592	$14,268.3022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$579.6860	$12,753.0922 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$654.5997	$19,637.9930 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$579.5152	$12,749.3322 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$615.2719	$13,535.9822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$654.5997	$19,637.9930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$623.8171	$13,723.9822 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$623.8171	$13,723.9822 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$583.9523	$12,846.9522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$617.5162	$13,585.3622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$617.5162	$13,585.3622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$663.6915	$19,910.7430 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$584.2234	$12,852.9122 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$617.5162	$13,585.3622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$663.6915	$19,910.7430 units	Prior authorization Quantity limit 21 per 21 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 Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$625.2450	$13,755.3922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$625.2450	$13,755.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$620.5239	$13,651.5322 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$620.5239	$13,651.5322 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$573.6860	$12,621.0922 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$649.5537	$19,486.6130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$573.6279	$12,619.8122 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$649.5537	$19,486.6130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$620.5239	$13,651.5322 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$605.0883	$13,311.9422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$605.0883	$13,311.9422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$569.2000	$12,522.4022 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$605.0883	$13,311.9422 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$608.6990	$13,391.3822 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$616.6619	$13,566.5622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$616.6619	$13,566.5622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$608.6990	$13,391.3822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$650.4656	$19,513.9730 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$582.9711	$12,825.3622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$583.2019	$12,830.4422 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$608.6990	$13,391.3822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$650.4656	$19,513.9730 units	Prior authorization Quantity limit 21 per 21 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
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$676.1980	$14,876.3622 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$621.5199	$13,673.4422 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$676.1980	$14,876.3622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$621.5199	$13,673.4422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$600.5140	$13,211.3122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$601.0325	$13,222.7222 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$660.5030	$19,815.0930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$621.5199	$13,673.4422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$660.5030	$19,815.0930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$586.0528	$12,893.1622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$586.0528	$12,893.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$585.6570	$12,884.4522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$613.3216	$13,493.0822 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$613.3216	$13,493.0822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$585.6570	$12,884.4522 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$613.3216	$13,493.0822 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$645.8517	$14,208.7422 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$618.9294	$13,616.4522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$618.9294	$13,616.4522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$645.8517	$14,208.7422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$613.3053	$13,492.7222 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$669.5868	$20,087.6030 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$613.3881	$13,494.5422 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$676.3400	$14,879.4822 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$669.5868	$20,087.6030 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$645.8517	$14,208.7422 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$580.9219	$12,780.2822 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$580.9219	$12,780.2822 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$578.8432	$12,734.5522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$615.0610	$13,531.3422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$615.0610	$13,531.3422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$645.4552	$19,363.6630 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$578.8572	$12,734.8622 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$615.0610	$13,531.3422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$645.4552	$19,363.6630 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$602.4100	$13,253.0222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$602.4100	$13,253.0222 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$601.6300	$13,235.8622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$601.6300	$13,235.8622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$567.6500	$12,488.3022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$567.6500	$12,488.3022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$567.6500	$12,488.3022 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$617.8423	$13,592.5322 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$617.8423	$13,592.5322 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$644.8731	$19,346.1930 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$617.8423	$13,592.5322 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$583.3616	$12,833.9622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$583.3616	$12,833.9622 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$634.7891	$19,043.6730 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$634.7891	$19,043.6730 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$586.5910	$12,905.0022 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$762.1200	$16,766.6422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$762.1200	$16,766.6422 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$762.1200	$16,766.6422 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$604.3272	$18,129.8230 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$604.3272	$18,129.8230 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$604.9706	$13,309.3522 units	Prior authorization Quantity limit 21 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	5Specialty Tier	25%	—	$646.6283	$19,398.8530 units	Prior authorization Quantity limit 21 per 21 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$622.5229	$13,695.5022 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$648.7344	$14,272.1622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$587.6388	$12,928.0522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$587.6388	$12,928.0522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$622.5229	$13,695.5022 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$622.5229	$13,695.5022 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$646.6283	$19,398.8530 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	—	$610.9357	$13,440.5922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$610.8195	$13,438.0322 units	Prior authorization Quantity limit 21 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$650.4263	$19,512.7930 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	25%	$672.1374	$20,164.1230 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	25%	$672.1374	$20,164.1230 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	25%	$672.1374	$20,164.1230 units	Prior authorization Quantity limit 21 per 21 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	5Specialty Tier	25%	25%	$672.1374	$20,164.1230 units	Prior authorization Quantity limit 21 per 21 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.

IBRANCE 125 mg Capsule

Coverage by region

Plan-by-plan detail