SKYRIZI Kit (Risankizumab-Rzaa) — 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%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17572.5931	$11,246.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17572.5931	$11,246.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17572.5931	$11,246.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17872.8115	$12,332.240.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17572.5931	$11,246.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$17872.8115	$12,332.240.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$18838.2692	$12,998.410.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17797.7705	$11,390.570.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17797.7705	$11,390.570.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18838.2692	$12,998.410.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19918.7001	$12,747.970.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17900.9308	$11,456.600.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17897.3540	$11,454.310.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19918.7001	$12,747.970.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18838.2692	$12,998.410.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$17960.4673	$11,494.700.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$17887.8785	$11,448.240.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$17667.2569	$11,307.040.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17667.2569	$11,307.040.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18879.4400	$13,026.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18879.4400	$13,026.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19439.3461	$12,441.180.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17688.8606	$11,320.870.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18789.6743	$12,964.880.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17687.6688	$11,320.110.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18879.4400	$13,026.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19439.3461	$12,441.180.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18789.6743	$12,964.880.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$19049.3126	$13,144.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18596.5311	$11,901.780.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18596.5311	$11,901.780.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19049.3126	$13,144.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20105.3208	$12,867.410.64 units	Prior authorization Quantity limit 1.2 per 56 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$18699.0885	$12,902.370.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18628.4575	$11,922.210.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18626.4143	$11,920.910.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19049.3126	$13,144.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20105.3208	$12,867.410.64 units	Prior authorization Quantity limit 1.2 per 56 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$18699.0885	$12,902.370.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$18224.1577	$11,663.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18224.1577	$11,663.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18504.1477	$11,842.650.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19015.8449	$13,120.930.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19015.8449	$13,120.930.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20584.4730	$13,174.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18509.5655	$11,846.120.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20584.4730	$13,174.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19473.6028	$19,473.601 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19015.8449	$13,120.930.69 units	Prior authorization Quantity limit 8.4 per 365 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19473.6028	$19,473.601 unit	Prior authorization Quantity limit 2.4 per 56 days

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

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18379.4300	$11,762.840.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18379.4300	$11,762.840.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18832.3518	$12,994.320.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18832.3518	$12,994.320.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20143.4623	$12,891.820.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18725.0900	$11,984.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19028.0580	$13,129.360.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20143.4623	$12,891.820.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18706.0200	$11,971.850.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18832.3518	$12,994.320.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19028.0580	$13,129.360.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18932.9263	$12,117.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20395.2729	$13,052.970.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18930.3697	$12,115.440.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20664.4640	$13,225.260.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$20395.2729	$13,052.970.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18834.5656	$12,054.120.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18834.5656	$12,054.120.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19227.3667	$13,266.880.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19227.3667	$13,266.880.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17696.5492	$11,325.790.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18158.7527	$12,529.540.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17688.8477	$11,320.860.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19227.3667	$13,266.880.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18158.7527	$12,529.540.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$19568.1553	$13,502.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19599.7915	$13,523.860.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18932.9263	$12,117.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19599.7915	$13,523.860.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18315.0644	$11,721.640.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18074.8267	$11,567.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18074.8267	$11,567.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18319.5689	$11,724.520.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19122.7643	$13,194.710.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20358.0080	$13,029.130.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19122.7643	$13,194.710.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20358.0080	$13,029.130.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19122.7643	$13,194.710.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19665.5850	$12,585.970.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19665.5850	$12,585.970.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18747.3466	$12,935.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17718.1052	$11,339.590.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19008.2237	$12,165.260.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17718.1052	$11,339.590.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19960.5163	$12,774.730.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18747.3466	$12,935.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18747.3466	$12,935.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17734.5613	$11,350.120.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19960.5163	$12,774.730.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19008.2237	$12,165.260.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$17568.9200	$11,244.110.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17568.9200	$11,244.110.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19262.0320	$13,290.800.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19262.0320	$13,290.800.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17568.9200	$11,244.110.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19702.4516	$12,609.570.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19262.0320	$13,290.800.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17568.9200	$11,244.110.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$19530.5426	$13,476.070.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18930.3697	$12,115.440.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18932.9263	$12,117.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19351.2721	$13,352.380.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$19107.6288	$13,184.260.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20327.3586	$13,009.510.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18063.4031	$11,560.580.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18063.4031	$11,560.580.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19107.6288	$13,184.260.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18271.0700	$11,693.480.64 units	Prior authorization Quantity limit 1.2 per 56 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19430.5877	$13,407.110.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19107.6288	$13,184.260.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18266.8463	$11,690.780.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20327.3586	$13,009.510.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18486.7050	$11,831.490.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18486.7050	$11,831.490.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19064.7850	$12,201.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$21037.4030	$13,463.940.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$21037.4030	$13,463.940.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19817.1150	$13,673.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20548.9500	$14,178.780.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$17674.2816	$11,311.540.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18702.9518	$11,969.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18702.9518	$11,969.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17674.2816	$11,311.540.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18976.6370	$13,093.880.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18976.6370	$13,093.880.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18976.6370	$13,093.880.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18932.9263	$12,117.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18930.3697	$12,115.440.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$17807.3073	$11,396.680.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17807.3073	$11,396.680.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18915.4251	$13,051.640.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18915.4251	$13,051.640.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17901.3614	$11,456.870.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20230.1474	$12,947.290.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18915.4251	$13,051.640.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20230.1474	$12,947.290.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17913.7141	$11,464.780.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$17854.2381	$11,426.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17854.2381	$11,426.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19358.0195	$13,357.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19358.0195	$13,357.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19451.8743	$13,421.790.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20054.0682	$12,834.600.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19358.0195	$13,357.030.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20054.0682	$12,834.600.64 units	Prior authorization Quantity limit 1.2 per 56 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19451.8743	$13,421.790.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$18997.8964	$13,108.550.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17825.7850	$11,408.500.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17825.7850	$11,408.500.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18997.8964	$13,108.550.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17898.7900	$11,455.230.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20024.2702	$12,815.530.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17896.4063	$11,453.700.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18997.8964	$13,108.550.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20024.2702	$12,815.530.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$19026.5908	$13,128.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18050.1063	$11,552.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18050.1063	$11,552.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19026.5908	$13,128.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18272.9530	$11,694.690.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$21089.5495	$13,497.310.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18262.2700	$11,687.850.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19026.5908	$13,128.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$21089.5495	$13,497.310.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$17766.6253	$11,370.640.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17766.6253	$11,370.640.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17699.5600	$11,327.720.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18760.3399	$12,944.630.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18760.3399	$12,944.630.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19979.5732	$12,786.930.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17697.9707	$11,326.700.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18760.3399	$12,944.630.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19979.5732	$12,786.930.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18052.9689	$11,553.900.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18052.9689	$11,553.900.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19297.7686	$13,315.460.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19297.7686	$13,315.460.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18237.4037	$11,671.940.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20529.4176	$13,138.830.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18226.3632	$11,664.870.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20529.4176	$13,138.830.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19297.7686	$13,315.460.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$17739.7633	$11,353.450.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17739.7633	$11,353.450.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17735.7900	$11,350.910.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17735.7900	$11,350.910.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18723.0924	$12,918.930.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17574.8863	$11,247.930.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17574.8863	$11,247.930.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18723.0924	$12,918.930.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19979.5732	$12,786.930.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17595.2981	$11,260.990.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17596.4900	$11,261.750.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18723.0924	$12,918.930.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19979.5732	$12,786.930.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18379.4300	$11,762.840.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18379.4300	$11,762.840.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18706.0200	$11,971.850.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18725.0900	$11,984.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$21096.9990	$13,502.080.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$21096.9990	$13,502.080.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18593.9800	$11,900.150.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18593.9800	$11,900.150.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18570.1400	$11,884.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18926.2607	$13,059.120.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18926.2607	$13,059.120.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18570.1400	$11,884.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18926.2607	$13,059.120.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$18474.7755	$12,747.600.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18450.9400	$11,808.600.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18450.9400	$11,808.600.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18474.7755	$12,747.600.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18298.3800	$11,710.960.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18300.7600	$11,712.490.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18474.7755	$12,747.600.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$17909.4714	$11,462.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17909.4714	$11,462.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18049.4386	$11,551.640.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19223.5464	$13,264.250.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19223.5464	$13,264.250.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20093.2761	$12,859.700.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18057.6114	$11,556.870.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19223.5464	$13,264.250.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20093.2761	$12,859.700.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$19070.7360	$13,158.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17974.1750	$11,503.470.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19070.7360	$13,158.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17974.1750	$11,503.470.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18147.0050	$11,614.080.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20501.0386	$13,120.660.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19070.7360	$13,158.810.69 units	Prior authorization Quantity limit 8.4 per 365 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18137.4700	$11,607.980.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20501.0386	$13,120.660.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18593.9800	$11,900.150.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18593.9800	$11,900.150.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18570.1400	$11,884.890.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19354.5267	$13,354.620.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19354.5267	$13,354.620.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19905.0781	$12,739.250.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19354.5267	$13,354.620.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$17447.3450	$11,166.300.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17447.3450	$11,166.300.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19279.3197	$12,338.760.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$18673.4290	$12,884.670.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$19279.3197	$12,338.760.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$17626.1350	$11,280.730.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18593.9800	$11,900.150.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19423.5500	$12,431.070.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18593.9800	$11,900.150.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20977.8069	$13,425.800.64 units	Prior authorization Quantity limit 1.2 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19547.5017	$12,510.400.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20977.8069	$13,425.800.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19468.0430	$13,432.950.69 units	Prior authorization Quantity limit 8.4 per 365 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%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$20664.4640	$13,225.260.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18987.0462	$12,151.710.64 units	Prior authorization Quantity limit 1.2 per 56 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$19935.2926	$13,755.350.69 units	Prior authorization Quantity limit 8.4 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$20667.9075	$13,227.460.64 units	Prior authorization Quantity limit 1.2 per 56 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%	—	$18725.0900	$11,984.060.64 units	Prior authorization Quantity limit 1.2 per 56 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$18706.0200	$11,971.850.64 units	Prior authorization Quantity limit 1.2 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$20179.2199	$12,914.700.64 units	Prior authorization Quantity limit 1.2 per 56 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%	$20746.6370	$13,277.850.64 units	Prior authorization Quantity limit 1.2 per 56 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%	$20746.6370	$13,277.850.64 units	Prior authorization Quantity limit 1.2 per 56 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%	$20746.6370	$13,277.850.64 units	Prior authorization Quantity limit 1.2 per 56 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%	$20746.6370	$13,277.850.64 units	Prior authorization Quantity limit 1.2 per 56 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.

SKYRIZI Kit

Coverage by region

Plan-by-plan detail