IBRANCE 100 mg Tablet, Film Coated (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%	—	$768.8234	$16,914.1122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$846.0419	$18,612.9222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$846.0419	$18,612.9222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$768.8234	$16,914.1122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$800.2272	$17,605.0022 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%	—	$767.4798	$16,884.5622 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%	—	$821.2855	$24,638.5630 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$799.9092	$17,598.0022 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$768.8234	$16,914.1122 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%	—	$821.2855	$24,638.5630 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%	—	$767.4798	$16,884.5622 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%	—	$767.0552	$16,875.2122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$763.3181	$16,793.0022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$763.3181	$16,793.0022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$767.0552	$16,875.2122 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$808.9236	$24,267.7130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$759.8422	$16,716.5322 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$759.8194	$16,716.0322 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%	—	$808.9236	$24,267.7130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$767.0552	$16,875.2122 units	Prior authorization Quantity limit 21 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$760.6222	$16,733.6922 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%	$760.8261	$16,738.1722 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%	—	$760.5167	$16,731.3722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$760.5167	$16,731.3722 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$771.6365	$16,976.0022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$771.6365	$16,976.0022 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%	—	$806.6652	$24,199.9630 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$760.0709	$16,721.5622 units	Prior authorization Quantity limit 21 per 28 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$790.5193	$17,391.4222 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$760.0694	$16,721.5322 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$771.6365	$16,976.0022 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%	—	$806.6652	$24,199.9630 units	Prior authorization Quantity limit 21 per 21 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$790.5193	$17,391.4222 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.

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%	—	$764.7085	$16,823.5922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$779.4438	$17,147.7622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$779.4438	$17,147.7622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$764.7085	$16,823.5922 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%	—	$806.6723	$24,200.1730 units	Prior authorization Quantity limit 21 per 21 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$792.3292	$17,431.2422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$779.2425	$17,143.3322 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$779.2425	$17,143.3322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$764.7085	$16,823.5922 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%	—	$806.6723	$24,200.1730 units	Prior authorization Quantity limit 21 per 21 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$792.3292	$17,431.2422 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.

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%	—	$752.0774	$16,545.7022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$752.0774	$16,545.7022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$750.8824	$16,519.4122 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$766.8288	$16,870.2322 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$766.8288	$16,870.2322 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%	—	$802.0889	$24,062.6730 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$751.3285	$16,529.2322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$802.0889	$24,062.6730 units	Prior authorization Quantity limit 21 per 21 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$774.0092	—	Prior authorization
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$766.8288	$16,870.2322 units	Prior authorization Quantity limit 21 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$774.0092	—	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%	—	$815.2804	$17,936.1722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$815.2804	$17,936.1722 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$765.5713	$16,842.5722 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$765.5713	$16,842.5722 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%	—	$820.7237	$24,621.7130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$769.5994	$16,931.1922 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$790.0428	$17,380.9422 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$820.7237	$24,621.7130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$769.2835	$16,924.2422 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$765.5713	$16,842.5722 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$790.0428	$17,380.9422 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%	—	$780.9177	$17,180.1922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$780.9177	$17,180.1922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$780.2291	$17,165.0422 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$783.8452	$17,244.5922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$780.2291	$17,165.0422 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%	—	$806.7020	$24,201.0630 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$808.4172	$17,785.1822 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$758.9766	$16,697.4922 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%	—	$806.7020	$24,201.0630 units	Prior authorization Quantity limit 21 per 21 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$783.8452	$17,244.5922 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%	—	$770.7907	$16,957.4022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$770.7907	$16,957.4022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$766.8920	$16,871.6222 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$766.8920	$16,871.6222 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$762.9693	$16,785.3222 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%	—	$809.6759	$24,290.2830 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$783.2650	$17,231.8322 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$762.9374	$16,784.6222 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%	—	$809.6759	$24,290.2830 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$766.8920	$16,871.6222 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$783.1432	$17,229.1522 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.

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%	—	$786.5450	$17,303.9922 units	Prior authorization Quantity limit 21 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$786.5450	$17,303.9922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$713.2800	$15,692.1622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$713.2800	$15,692.1622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$713.2800	$15,692.1622 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$764.5512	$16,820.1322 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$764.5512	$16,820.1322 units	Prior authorization Quantity limit 21 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$786.5450	$17,303.9922 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$758.1693	$22,745.0830 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$764.5512	$16,820.1322 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%	—	$758.1693	$22,745.0830 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%	—	$766.9690	$16,873.3222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$797.2577	$17,539.6722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$797.2577	$17,539.6722 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$767.1963	$16,878.3222 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$771.3738	$16,970.2222 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%	—	$815.2338	$24,457.0130 units	Prior authorization Quantity limit 21 per 21 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$771.3738	$16,970.2222 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%	—	$815.2338	$24,457.0130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$771.3738	$16,970.2222 units	Prior authorization Quantity limit 21 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$788.1432	$17,339.1522 units	Prior authorization Quantity limit 21 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$788.1432	$17,339.1522 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.

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%	—	$763.0548	$16,787.2122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.6004	$16,645.2122 units	Prior authorization Quantity limit 21 per 28 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$771.7698	$16,978.9422 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.6004	$16,645.2122 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$810.1873	$24,305.6230 units	Prior authorization Quantity limit 21 per 21 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$763.0548	$16,787.2122 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$763.0548	$16,787.2122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$755.0282	$16,610.6222 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%	—	$810.1873	$24,305.6230 units	Prior authorization Quantity limit 21 per 21 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$771.7698	$16,978.9422 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%	—	$752.5294	$16,555.6522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$752.5294	$16,555.6522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$759.2591	$16,703.7022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$759.2591	$16,703.7022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$752.5294	$16,555.6522 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$809.0369	$24,271.1130 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$800.6781	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$759.2591	$16,703.7022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$752.5294	$16,555.6522 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%	—	$787.1238	$17,316.7222 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$748.2277	$16,461.0122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$748.2277	$16,461.0122 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$746.4448	$16,421.7922 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$758.9766	$16,697.4922 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$746.4448	$16,421.7922 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$787.1238	$17,316.7222 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%	—	$763.8580	$16,804.8822 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%	—	$810.8074	$24,324.2230 units	Prior authorization Quantity limit 21 per 21 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$785.0295	$17,270.6522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$785.0295	$17,270.6522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$763.8580	$16,804.8822 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$771.6022	$16,975.2522 units	Prior authorization Quantity limit 21 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$787.2319	$17,319.1022 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$763.8580	$16,804.8822 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$771.5095	$16,973.2122 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%	—	$810.8074	$24,324.2230 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%	—	$749.5733	$16,490.6122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$749.5733	$16,490.6122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$749.5733	$16,490.6122 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$758.9766	$16,697.4922 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$758.9766	$16,697.4922 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$746.8729	$16,431.2022 units	Prior authorization Quantity limit 21 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$746.8729	$16,431.2022 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%	—	$773.6674	$17,020.6822 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$784.3046	$17,254.7022 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$784.3046	$17,254.7022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$773.6793	$17,020.9422 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%	—	$810.3157	$24,309.4730 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$777.0134	$17,094.2922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$777.0134	$17,094.2922 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%	—	$810.3157	$24,309.4730 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$777.0134	$17,094.2922 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%	—	$755.5085	$16,621.1922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$755.5085	$16,621.1922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$782.4331	$17,213.5322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$782.4331	$17,213.5322 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$755.3638	$16,618.0022 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%	—	$817.7668	$24,533.0030 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$755.5508	$16,622.1222 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%	—	$817.7668	$24,533.0030 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$755.5085	$16,621.1922 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%	—	$779.8097	$17,155.8122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$779.8097	$17,155.8122 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$762.4701	$16,774.3422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$762.4701	$16,774.3422 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$763.7439	$16,802.3722 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%	—	$813.4911	$24,404.7330 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$762.4701	$16,774.3422 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%	—	$813.4911	$24,404.7330 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$763.6334	$16,799.9322 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%	—	$766.3031	$16,858.6722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$766.3031	$16,858.6722 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$781.5747	$17,194.6422 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$781.5747	$17,194.6422 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$788.0364	$17,336.8022 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%	—	$810.5179	$24,315.5430 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$781.5747	$17,194.6422 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%	—	$810.5179	$24,315.5430 units	Prior authorization Quantity limit 21 per 21 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$788.0364	$17,336.8022 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%	—	$767.7860	$16,891.2922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$778.0287	$17,116.6322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$778.0287	$17,116.6322 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$767.7860	$16,891.2922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$765.9690	$16,851.3222 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%	—	$810.7594	$24,322.7830 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$765.8868	$16,849.5122 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$767.7860	$16,891.2922 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%	—	$810.7594	$24,322.7830 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%	—	$774.8812	$17,047.3922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$781.5634	$17,194.3922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$781.5634	$17,194.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$774.8812	$17,047.3922 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8750	$17,905.2522 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$759.7610	$16,714.7422 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%	—	$815.4132	$24,462.4030 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$759.6094	$16,711.4122 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$774.8812	$17,047.3922 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%	—	$815.4132	$24,462.4030 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%	—	$797.0688	$17,535.5122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$797.0688	$17,535.5122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$761.6927	$16,757.2422 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$768.7200	$16,911.8422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$768.7200	$16,911.8422 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%	—	$823.6519	$24,709.5630 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$761.9352	$16,762.5722 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$768.7200	$16,911.8422 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%	—	$823.6519	$24,709.5630 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%	—	$806.2373	$17,737.2222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$806.2373	$17,737.2222 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$771.2494	$16,967.4922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$771.2494	$16,967.4922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$765.3694	$16,838.1322 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%	—	$823.8904	$24,716.7130 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$765.0923	$16,832.0322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$823.8904	$24,716.7130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$771.2494	$16,967.4922 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%	—	$750.3347	$16,507.3622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$750.3347	$16,507.3622 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$766.3358	$16,859.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$766.3358	$16,859.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$750.3347	$16,507.3622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$750.3347	$16,507.3622 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$766.3358	$16,859.3922 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$809.0369	$24,271.1130 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%	—	$774.2378	$17,033.2322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$852.8299	$18,762.2622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$852.8299	$18,762.2622 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$774.2378	$17,033.2322 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%	—	$835.7439	$25,072.3230 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$780.7741	$17,177.0322 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$781.2717	$17,187.9822 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$774.2378	$17,033.2322 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%	—	$835.7439	$25,072.3230 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%	—	$769.1998	$16,922.4022 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$766.3487	$16,859.6722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$769.1998	$16,922.4022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$766.3487	$16,859.6722 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.9128	$16,652.0822 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.9976	$16,653.9522 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$814.0485	$24,421.4530 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$766.3487	$16,859.6722 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%	—	$814.0485	$24,421.4530 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%	—	$838.3894	$18,444.5722 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$838.3894	$18,444.5722 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$794.6606	$17,482.5322 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$776.1929	$17,076.2422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$776.1929	$17,076.2422 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%	—	$816.5113	$24,495.3430 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$794.9582	$17,489.0822 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$816.5113	$24,495.3430 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$776.1929	$17,076.2422 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.

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%	—	$791.2735	$17,408.0222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$895.3833	$19,698.4322 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$895.3833	$19,698.4322 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$791.2735	$17,408.0222 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$793.1159	$17,448.5522 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%	—	$851.5674	$25,547.0230 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$792.4048	$17,432.9122 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$851.5674	$25,547.0230 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$791.2735	$17,408.0222 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%	—	$776.8866	$17,091.5122 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$776.8866	$17,091.5122 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$764.6360	$16,821.9922 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$764.9809	$16,829.5822 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$764.9809	$16,829.5822 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%	—	$812.4401	$24,373.2030 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$764.7194	$16,823.8322 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$764.9809	$16,829.5822 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%	—	$812.4401	$24,373.2030 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%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.4205	$16,641.2522 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.4205	$16,641.2522 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.0117	$16,632.2622 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$758.9766	$16,697.4922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$756.0117	$16,632.2622 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%	—	$809.0369	$24,271.1130 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%	—	$752.8529	$16,562.7622 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$752.8529	$16,562.7622 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$752.7589	$16,560.7022 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$763.0871	$16,787.9222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$763.0871	$16,787.9222 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$763.0871	$16,787.9222 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.

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%	—	$768.6657	$16,910.6522 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$768.6657	$16,910.6522 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$759.2729	$16,704.0022 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$759.2729	$16,704.0022 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%	—	$806.5396	$24,196.1930 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$759.2729	$16,704.0022 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%	—	$806.5396	$24,196.1930 units	Prior authorization Quantity limit 21 per 21 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$768.0926	$16,898.0422 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%	—	$815.3092	$17,936.8022 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$808.0095	$17,776.2122 units	Prior authorization Quantity limit 21 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$810.2647	$17,825.8222 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$810.2647	$17,825.8222 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$815.3092	$17,936.8022 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%	—	$840.0419	$25,201.2630 units	Prior authorization Quantity limit 21 per 21 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$848.5142	$18,667.3122 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%	—	$840.0419	$25,201.2630 units	Prior authorization Quantity limit 21 per 21 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$810.2647	$17,825.8222 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%	—	$809.0369	$24,271.1130 units	Prior authorization Quantity limit 21 per 21 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$781.0205	$17,182.4522 units	Prior authorization Quantity limit 21 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$813.8812	$17,905.3922 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$753.8700	$16,585.1422 units	Prior authorization Quantity limit 21 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$753.8700	$16,585.1422 units	Prior authorization Quantity limit 21 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$781.0205	$17,182.4522 units	Prior authorization Quantity limit 21 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$781.0205	$17,182.4522 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%	—	$809.0369	$24,271.1130 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%	—	$810.7858	$17,837.2922 units	Prior authorization Quantity limit 21 per 28 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$810.3698	$17,828.1422 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%	$816.4608	$24,493.8230 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%	$843.2418	$25,297.2530 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%	$843.2418	$25,297.2530 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%	$843.2418	$25,297.2530 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%	$843.2418	$25,297.2530 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 100 mg Tablet, Film Coated

Coverage by region

Plan-by-plan detail