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%	—	$9491.2228	$9,491.221 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8988.0197	$8,988.021 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8988.0197	$8,988.021 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9491.2228	$9,491.221 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9057.9330	$9,057.931 unit	Prior authorization Quantity limit 2.4 per 56 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9490.9544	$9,490.951 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10173.8053	$10,173.811 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9054.3158	$9,054.321 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9491.2228	$9,491.221 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10173.8053	$10,173.811 unit	Prior authorization Quantity limit 2.4 per 56 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$9490.9544	$9,490.951 unit	Prior authorization Quantity limit 16.8 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%	—	$9474.5785	$9,474.581 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8826.0682	$8,826.071 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8826.0682	$8,826.071 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9474.5785	$9,474.581 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9954.1578	$9,954.161 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8829.6440	$8,829.641 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8829.0012	$8,829.001 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9954.1578	$9,954.161 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9474.5785	$9,474.581 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$8845.7348	$8,845.731 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$8838.2562	$8,838.261 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.

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%	—	$8824.3511	$8,824.351 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8824.3511	$8,824.351 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9377.2560	$9,377.261 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9377.2560	$9,377.261 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9939.6393	$9,939.641 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8840.1226	$8,840.121 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9401.7762	$9,401.781 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8839.2521	$8,839.251 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9377.2560	$9,377.261 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9939.6393	$9,939.641 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9401.7762	$9,401.781 unit	Prior authorization Quantity limit 16.8 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%	—	$9459.0335	$9,459.031 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9358.5987	$9,358.601 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9358.5987	$9,358.601 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9459.0335	$9,459.031 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9860.3681	$9,860.371 unit	Prior authorization Quantity limit 2.4 per 56 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$9094.9930	$9,094.991 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9391.1009	$9,391.101 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9389.4654	$9,389.471 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9459.0335	$9,459.031 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9860.3681	$9,860.371 unit	Prior authorization Quantity limit 2.4 per 56 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$9094.9930	$9,094.991 unit	Prior authorization Quantity limit 16.8 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%	—	$8852.7034	$8,852.701 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8852.7034	$8,852.701 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8953.5850	$8,953.581 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9533.2900	$9,533.291 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9533.2900	$9,533.291 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9792.2780	$9,792.281 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8959.9831	$8,959.981 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9792.2780	$9,792.281 unit	Prior authorization Quantity limit 2.4 per 56 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9553.6245	$9,553.621 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%	—	$9533.2900	$9,533.291 unit	Prior authorization Quantity limit 16.8 per 365 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9553.6245	$9,553.621 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%	—	$8922.9299	$8,922.931 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8922.9299	$8,922.931 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9378.4697	$9,378.471 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9378.4697	$9,378.471 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10001.2034	$10,001.201 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8984.5537	$8,984.551 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9031.1047	$9,031.101 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10001.2034	$10,001.201 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8981.7564	$8,981.761 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9378.4697	$9,378.471 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9024.1126	$9,024.111 unit	Prior authorization Quantity limit 16.8 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%	—	$8883.5821	$8,883.581 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8883.5821	$8,883.581 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8909.3647	$8,909.361 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9379.2831	$9,379.281 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9379.2831	$9,379.281 unit	Prior authorization Quantity limit 16.8 per 365 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9642.6396	$9,642.641 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8910.8711	$8,910.871 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9861.5488	$9,861.551 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9379.2831	$9,379.281 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9861.5488	$9,861.551 unit	Prior authorization Quantity limit 2.4 per 56 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9642.6396	$9,642.641 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.

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%	—	$9486.9896	$9,486.991 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9486.9896	$9,486.991 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9589.5462	$9,589.551 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9589.5462	$9,589.551 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8828.8459	$8,828.851 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9953.3906	$9,953.391 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9096.5536	$9,096.551 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8827.8000	$8,827.801 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9953.3906	$9,953.391 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9589.5462	$9,589.551 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9093.7815	$9,093.781 unit	Prior authorization Quantity limit 16.8 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%	—	$8892.0799	$8,892.081 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8892.0799	$8,892.081 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8409.2390	$8,409.241 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8405.6892	$8,405.691 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8405.6892	$8,405.691 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9427.3651	$9,427.371 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9427.3651	$9,427.371 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$8892.0799	$8,892.081 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9398.6846	$9,398.681 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9427.3651	$9,427.371 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9398.6846	$9,398.681 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.

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%	—	$8848.7588	$8,848.761 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8760.7706	$8,760.771 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8760.7706	$8,760.771 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8850.4925	$8,850.491 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9438.1974	$9,438.201 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9826.6677	$9,826.671 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9438.1974	$9,438.201 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9826.6677	$9,826.671 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9438.1974	$9,438.201 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9688.9126	$9,688.911 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9688.9126	$9,688.911 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.

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%	—	$9353.3292	$9,353.331 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8810.4466	$8,810.451 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9531.1963	$9,531.201 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8810.4466	$8,810.451 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9968.8725	$9,968.871 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9353.3292	$9,353.331 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9353.3292	$9,353.331 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8821.9645	$8,821.961 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9968.8725	$9,968.871 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9531.1963	$9,531.201 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.

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%	—	$9270.3641	$9,270.361 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9270.3641	$9,270.361 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9597.9274	$9,597.931 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9597.9274	$9,597.931 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9275.0200	$9,275.021 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9953.8045	$9,953.801 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9953.8045	$9,953.801 unit	Prior authorization Quantity limit 2.4 per 56 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9851.1753	$9,851.181 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9597.9274	$9,597.931 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9274.7219	$9,274.721 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.

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%	—	$9410.7718	$9,410.771 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9513.4154	$9,513.421 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9105.3520	$9,105.351 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9105.3520	$9,105.351 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9513.4154	$9,513.421 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9172.2483	$9,172.251 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10162.6368	$10,162.641 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9513.4154	$9,513.421 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10162.6368	$10,162.641 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9168.3770	$9,168.381 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9404.5856	$9,404.591 unit	Prior authorization Quantity limit 16.8 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%	—	$9429.9535	$9,429.951 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9942.6386	$9,942.641 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9010.2728	$9,010.271 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9010.2728	$9,010.271 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9429.9535	$9,429.951 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9047.4706	$9,047.471 unit	Prior authorization Quantity limit 2.4 per 56 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9360.7510	$9,360.751 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9429.9535	$9,429.951 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9046.2902	$9,046.291 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9942.6386	$9,942.641 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.

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%	—	$8760.6300	$8,760.631 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8760.6300	$8,760.631 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8760.6300	$8,760.631 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9336.7145	$9,336.711 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9827.3875	$9,827.391 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9336.7145	$9,336.711 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9336.7145	$9,336.711 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9827.3875	$9,827.391 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9421.1800	$9,421.181 unit	Prior authorization Quantity limit 16.8 per 365 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9421.1800	$9,421.181 unit	Prior authorization Quantity limit 16.8 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%	—	$8956.1328	$8,956.131 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9164.0359	$9,164.041 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9164.0359	$9,164.041 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8956.6827	$8,956.681 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9967.3929	$9,967.391 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9447.3350	$9,447.331 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9447.3350	$9,447.331 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9967.3929	$9,967.391 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9447.3350	$9,447.331 unit	Prior authorization Quantity limit 16.8 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%	—	$9239.9610	$9,239.961 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9239.9610	$9,239.961 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8790.5941	$8,790.591 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8790.5941	$8,790.591 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8795.0021	$8,795.001 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9758.7715	$9,758.771 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8795.3218	$8,795.321 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9758.7715	$9,758.771 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9239.9610	$9,239.961 unit	Prior authorization Quantity limit 16.8 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%	—	$9097.9428	$9,097.941 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9097.9428	$9,097.941 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9649.7585	$9,649.761 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9649.7585	$9,649.761 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9211.7798	$9,211.781 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10273.9624	$10,273.961 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9649.7585	$9,649.761 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10273.9624	$10,273.961 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9209.2139	$9,209.211 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.

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%	—	$8983.4385	$8,983.441 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8983.4385	$8,983.441 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9466.3853	$9,466.391 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9466.3853	$9,466.391 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9485.3672	$9,485.371 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9902.2136	$9,902.211 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9466.3853	$9,466.391 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9902.2136	$9,902.211 unit	Prior authorization Quantity limit 2.4 per 56 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9485.3672	$9,485.371 unit	Prior authorization Quantity limit 16.8 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%	—	$9455.3349	$9,455.331 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9119.9434	$9,119.941 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9119.9434	$9,119.941 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9455.3349	$9,455.331 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9168.7166	$9,168.721 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9996.2430	$9,996.241 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9165.7579	$9,165.761 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9455.3349	$9,455.331 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9996.2430	$9,996.241 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.

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%	—	$9451.5885	$9,451.591 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8861.9218	$8,861.921 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8861.9218	$8,861.921 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9451.5885	$9,451.591 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8882.6990	$8,882.701 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10016.3519	$10,016.351 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8883.6458	$8,883.651 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9451.5885	$9,451.591 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10016.3519	$10,016.351 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.

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%	—	$8893.1857	$8,893.191 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8893.1857	$8,893.191 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8901.2516	$8,901.251 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9396.9125	$9,396.911 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9396.9125	$9,396.911 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10047.5145	$10,047.511 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8902.5956	$8,902.601 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9396.9125	$9,396.911 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10047.5145	$10,047.511 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.

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%	—	$9123.4972	$9,123.501 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9123.4972	$9,123.501 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9593.9636	$9,593.961 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9593.9636	$9,593.961 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8946.6270	$8,946.631 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10074.5032	$10,074.501 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8945.1274	$8,945.131 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10074.5032	$10,074.501 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9593.9636	$9,593.961 unit	Prior authorization Quantity limit 16.8 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%	—	$8792.4157	$8,792.421 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8792.4157	$8,792.421 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9466.2489	$9,466.251 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9466.2489	$9,466.251 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8794.4316	$8,794.431 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8794.5494	$8,794.551 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9590.3786	$9,590.381 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9466.2489	$9,466.251 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9590.3786	$9,590.381 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.

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%	—	$9379.6666	$9,379.671 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8841.6537	$8,841.651 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8841.6537	$8,841.651 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9379.6666	$9,379.671 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10009.9876	$10,009.991 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8872.6569	$8,872.661 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8873.5545	$8,873.551 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9379.6666	$9,379.671 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10009.9876	$10,009.991 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.

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%	—	$9023.6743	$9,023.671 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9511.3478	$9,511.351 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9023.6743	$9,023.671 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9511.3478	$9,511.351 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9099.7297	$9,099.731 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9098.7455	$9,098.751 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10181.5750	$10,181.581 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9511.3478	$9,511.351 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10181.5750	$10,181.581 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.

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%	—	$8947.1074	$8,947.111 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8947.1074	$8,947.111 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8992.3226	$8,992.321 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9604.1787	$9,604.181 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9604.1787	$9,604.181 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10017.6975	$10,017.701 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8996.6303	$8,996.631 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10017.6975	$10,017.701 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9604.1787	$9,604.181 unit	Prior authorization Quantity limit 16.8 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%	—	$9237.3878	$9,237.391 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9225.4800	$9,225.481 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9225.4800	$9,225.481 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9237.3878	$9,237.391 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9149.1900	$9,149.191 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9952.5392	$9,952.541 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9150.3900	$9,150.391 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9952.5392	$9,952.541 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9237.3878	$9,237.391 unit	Prior authorization Quantity limit 16.8 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%	—	$8965.8724	$8,965.871 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8965.8724	$8,965.871 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8975.1807	$8,975.181 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9382.5665	$9,382.571 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9382.5665	$9,382.571 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9987.9243	$9,987.921 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8976.3438	$8,976.341 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9382.5665	$9,382.571 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9987.9243	$9,987.921 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.

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%	—	$9343.8093	$9,343.811 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9060.9705	$9,060.971 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9343.8093	$9,343.811 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9060.9705	$9,060.971 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9056.7132	$9,056.711 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9963.1814	$9,963.181 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9343.8093	$9,343.811 unit	Prior authorization Quantity limit 16.8 per 365 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9056.5429	$9,056.541 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9963.1814	$9,963.181 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.

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%	—	$8864.3271	$8,864.331 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8864.3271	$8,864.331 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8902.0858	$8,902.091 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9402.2702	$9,402.271 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9402.2702	$9,402.271 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9999.0241	$9,999.021 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9999.0241	$9,999.021 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9402.2702	$9,402.271 unit	Prior authorization Quantity limit 16.8 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%	—	$8710.6974	$8,710.701 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8710.6974	$8,710.701 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9392.3375	$9,392.341 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9392.3375	$9,392.341 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9537.0490	$9,537.051 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9392.3375	$9,392.341 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9537.0490	$9,537.051 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8865.7459	$8,865.751 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.

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%	—	$9296.9900	$9,296.991 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9285.0700	$9,285.071 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9336.7145	$9,336.711 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9336.7145	$9,336.711 unit	Prior authorization Quantity limit 16.8 per 365 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9296.9900	$9,296.991 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10131.3273	$10,131.331 unit	Prior authorization Quantity limit 2.4 per 56 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10131.3273	$10,131.331 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9336.7145	$9,336.711 unit	Prior authorization Quantity limit 16.8 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%	—	$10065.4580	$10,065.461 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9538.9154	$9,538.921 unit	Prior authorization Quantity limit 16.8 per 365 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9773.7509	$9,773.751 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8800.3600	$8,800.361 unit	Prior authorization Quantity limit 2.4 per 56 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8800.3600	$8,800.361 unit	Prior authorization Quantity limit 2.4 per 56 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$9538.9154	$9,538.921 unit	Prior authorization Quantity limit 16.8 per 365 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$9538.9154	$9,538.921 unit	Prior authorization Quantity limit 16.8 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$10065.4580	$10,065.461 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.

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%	—	$9922.7500	$9,922.751 unit	Prior authorization Quantity limit 2.4 per 56 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9922.7500	$9,922.751 unit	Prior authorization Quantity limit 2.4 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$9952.5392	$9,952.541 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.

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%	$10373.3186	$10,373.321 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.

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%	$10373.3186	$10,373.321 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.

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%	$10373.3186	$10,373.321 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.

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%	$10373.3186	$10,373.321 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.

SKYRIZI Kit

Coverage by region

Plan-by-plan detail