OZEMPIC .68 mg/mL Injection, Solution (Semaglutide) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	3–6	$11.00	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	3–6	$11.00	12 of 12 plans
North Carolina	12 of 12	3–6	$11.00	12 of 12 plans
Alabama and Tennessee	12 of 12	3–6	$11.00	12 of 12 plans
Michigan	12 of 12	3–6	$11.00	12 of 12 plans
Illinois	12 of 12	3–6	$11.00	12 of 12 plans
Arkansas	12 of 12	3–6	$11.00	12 of 12 plans
Texas	12 of 12	3–6	$11.00	12 of 12 plans
Kansas	12 of 12	3–6	$11.00	12 of 12 plans
California	12 of 12	3–6	$11.00	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	3–6	$11.00	11 of 11 plans
South Carolina	11 of 11	3–6	$11.00	11 of 11 plans
Oklahoma	11 of 11	3–6	$11.00	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	3–6	$11.00	11 of 11 plans
New Mexico	11 of 11	3–6	$11.00	11 of 11 plans
New York	10 of 10	3–6	$11.00	10 of 10 plans
Delaware, DC and Maryland	10 of 10	3–6	$11.00	10 of 10 plans
Georgia	10 of 10	3–6	$11.00	10 of 10 plans
Florida	10 of 10	3–6	$11.00	10 of 10 plans
Ohio	10 of 10	3–6	$11.00	10 of 10 plans
Indiana and Kentucky	10 of 10	3–6	$11.00	10 of 10 plans
Wisconsin	10 of 10	3–6	$11.00	10 of 10 plans
Missouri	10 of 10	3–6	$11.00	10 of 10 plans
Mississippi	10 of 10	3–6	$11.00	10 of 10 plans
Louisiana	10 of 10	3–6	$11.00	10 of 10 plans
Colorado	10 of 10	3–6	$11.00	10 of 10 plans
Arizona	10 of 10	3–6	$11.00	10 of 10 plans
Nevada	10 of 10	3–6	$11.00	10 of 10 plans
Oregon and Washington	10 of 10	3–6	$11.00	10 of 10 plans
Idaho and Utah	10 of 10	3–6	$11.00	10 of 10 plans
Maine and New Hampshire	9 of 9	3–6	$11.00	9 of 9 plans
Virginia	9 of 9	3–6	$11.00	9 of 9 plans
Alaska	9 of 9	3–6	$11.00	9 of 9 plans
Hawaii	8 of 8	3–6	$11.00	8 of 8 plans
Puerto Rico	3 of 3	3	—	3 of 3 plans
American Samoa	1 of 1	3	—	1 of 1 plans
Guam	1 of 1	3	—	1 of 1 plans
Northern Mariana Islands	1 of 1	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	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	3Preferred Brand	25%	20%	$329.0244	$987.073 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$311.4757	$934.433 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$329.0244	$987.073 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$323.1206	$969.363 units	Prior authorization Quantity limit 3 per 28 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$338.1150	$1,014.353 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$347.8344	$1,043.503 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$323.1316	$969.393 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.0244	$987.073 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$347.8344	$1,043.503 units	Prior authorization Quantity limit 3 per 28 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$338.1150	$1,014.353 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9135	$998.743 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$311.4757	$934.433 units	Prior authorization Quantity limit 3 per 28 days

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

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$328.9326	$986.803 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.5921	$940.783 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$328.9326	$986.803 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9528	$998.863 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$347.0339	$1,041.103 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$323.9219	$971.773 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$323.9617	$971.893 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$347.0339	$1,041.103 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$328.9326	$986.803 units	Prior authorization Quantity limit 3 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$324.6623	$973.993 units	Prior authorization Quantity limit 3 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$323.6030	$970.813 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$313.5921	$940.783 units	Prior authorization Quantity limit 3 per 28 days

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

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$315.9866	$947.963 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.6096	$988.833 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.6096	$988.833 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$350.9110	$1,052.733 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$327.6741	$983.023 units	Prior authorization Quantity limit 3 per 28 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$342.8514	$1,028.553 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$328.0292	$984.093 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.6096	$988.833 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$350.9110	$1,052.733 units	Prior authorization Quantity limit 3 per 28 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$342.8514	$1,028.553 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9675	$998.903 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$315.9866	$947.963 units	Prior authorization Quantity limit 3 per 28 days

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

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.0233	$987.073 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$316.6905	$950.073 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.0233	$987.073 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$351.3887	$1,054.173 units	Prior authorization Quantity limit 3 per 28 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$341.8892	$1,025.673 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.1025	$978.313 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$326.9026	$980.713 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.0233	$987.073 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$351.3887	$1,054.173 units	Prior authorization Quantity limit 3 per 28 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	3Preferred Brand	$47.00	$94.00	$341.8892	$1,025.673 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9970	$998.993 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$316.6905	$950.073 units	Prior authorization Quantity limit 3 per 28 days

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

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$315.4952	$946.493 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$324.4788	$973.443 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.8159	$989.453 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.8159	$989.453 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$348.2887	$1,044.873 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$323.9614	$971.883 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$348.2887	$1,044.873 units	Prior authorization Quantity limit 3 per 28 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$327.9531	$983.863 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.8159	$989.453 units	Prior authorization Quantity limit 3 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$327.9531	$983.863 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9460	$998.843 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$315.4952	$946.493 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$316.0001	$948.003 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$331.6168	$994.853 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$331.6168	$994.853 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$352.8638	$1,058.593 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$328.0438	$984.133 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$339.4826	$1,018.453 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$352.8638	$1,058.593 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$328.2651	$984.803 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$331.6168	$994.853 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$334.5581	$1,003.673 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9776	$998.933 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$316.0001	$948.003 units	Prior authorization Quantity limit 3 per 28 days

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

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$315.9629	$947.893 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$323.9950	$971.993 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$327.8039	$983.413 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$327.8039	$983.413 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.8729	$998.623 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$323.5154	$970.553 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$352.4517	$1,057.363 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$327.8039	$983.413 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$352.4517	$1,057.363 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$332.8729	$998.623 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.2199	$999.663 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$315.9629	$947.893 units	Prior authorization Quantity limit 3 per 28 days

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

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$314.9992	$945.003 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$328.3727	$985.123 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$328.3727	$985.123 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.4559	$976.373 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$350.6240	$1,051.873 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$340.5534	$1,021.663 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.5421	$976.633 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$350.6240	$1,051.873 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$328.3727	$985.123 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$334.4564	$1,003.373 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9692	$998.913 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$314.9992	$945.003 units	Prior authorization Quantity limit 3 per 28 days

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

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$343.4092	$1,030.233 units	Prior authorization Quantity limit 3 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$343.2058	$1,029.623 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$330.3883	$991.163 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$324.4637	$973.393 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.7015	$989.103 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.7015	$989.103 units	Prior authorization Quantity limit 3 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$343.2058	$1,029.623 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$349.7531	$1,049.263 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.7015	$989.103 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$349.7531	$1,049.263 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$334.8392	$1,004.523 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$324.4637	$973.393 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$325.6866	$977.063 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.3750	$940.123 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.7041	$977.113 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$329.8232	$989.473 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$347.4446	$1,042.333 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.8232	$989.473 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$347.4446	$1,042.333 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.8232	$989.473 units	Prior authorization Quantity limit 3 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$336.7636	$1,010.293 units	Prior authorization Quantity limit 3 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$336.7636	$1,010.293 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9471	$998.843 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$313.3750	$940.123 units	Prior authorization Quantity limit 3 per 28 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$330.7906	$992.373 units	Prior authorization Quantity limit 3 per 28 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.8825	$980.653 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$312.8508	$938.553 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9322	$998.803 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$347.4909	$1,042.473 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$330.7906	$992.373 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.7906	$992.373 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$327.3186	$981.963 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$347.4909	$1,042.473 units	Prior authorization Quantity limit 3 per 28 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$326.8825	$980.653 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$312.8508	$938.553 units	Prior authorization Quantity limit 3 per 28 days

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

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$314.3800	$943.143 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$330.2652	$990.803 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$330.2652	$990.803 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.3967	$979.193 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$348.9801	$1,046.943 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$348.9801	$1,046.943 units	Prior authorization Quantity limit 3 per 28 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$329.3649	$988.093 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.2652	$990.803 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$327.0635	$981.193 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9657	$998.903 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$314.3800	$943.143 units	Prior authorization Quantity limit 3 per 28 days

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

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$339.1074	$1,017.323 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$327.3055	$981.923 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$335.4921	$1,006.483 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$327.3055	$981.923 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$344.1898	$1,032.573 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$347.5176	$1,042.553 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$327.3055	$981.923 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$347.5176	$1,042.553 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$344.1854	$1,032.563 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$339.4176	$1,018.253 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$335.4921	$1,006.483 units	Prior authorization Quantity limit 3 per 28 days

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.0651	$987.203 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$348.7726	$1,046.323 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$322.4591	$967.383 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.0651	$987.203 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$334.0690	$1,002.213 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.4126	$976.243 units	Prior authorization Quantity limit 3 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$344.3295	$1,032.993 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.0651	$987.203 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.6119	$976.843 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$348.7726	$1,046.323 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$322.4591	$967.383 units	Prior authorization Quantity limit 3 per 28 days

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

New 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	3Preferred Brand	25%	25%	$331.9572	$995.873 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$341.3086	$1,023.933 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$328.6786	$986.043 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$349.8581	$1,049.573 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$328.6786	$986.043 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$328.6786	$986.043 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$349.8581	$1,049.573 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	3Preferred Brand	14%	14%	$337.3280	$1,011.983 units	Prior authorization Quantity limit 3 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$345.6446	$1,036.933 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.2034	$999.613 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$331.9572	$995.873 units	Prior authorization Quantity limit 3 per 28 days

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

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$320.2682	$960.803 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$311.1759	$933.533 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$320.3496	$961.053 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$346.8188	$1,040.463 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$327.5979	$982.793 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$327.5979	$982.793 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$346.8188	$1,040.463 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$327.5979	$982.793 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9779	$998.933 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$311.1759	$933.533 units	Prior authorization Quantity limit 3 per 28 days

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

Delaware, DC and Maryland — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.6553	$988.973 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.6553	$988.973 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.5022	$940.513 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$325.6049	$976.813 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$348.5730	$1,045.723 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.5255	$976.583 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$348.5730	$1,045.723 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.6553	$988.973 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9398	$998.823 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$313.5022	$940.513 units	Prior authorization Quantity limit 3 per 28 days

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

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$317.0266	$951.083 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$330.1766	$990.533 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$330.1766	$990.533 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.5439	$976.633 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$349.5587	$1,048.683 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.1766	$990.533 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$349.5587	$1,048.683 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$326.9036	$980.713 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.1523	$999.463 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$317.0266	$951.083 units	Prior authorization Quantity limit 3 per 28 days

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

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$314.1537	$942.463 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$330.4741	$991.423 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$330.4741	$991.423 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$344.5522	$1,033.663 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$349.8554	$1,049.573 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.4741	$991.423 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$349.8554	$1,049.573 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$344.5522	$1,033.663 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9301	$998.793 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$314.1537	$942.463 units	Prior authorization Quantity limit 3 per 28 days

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

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.5740	$988.723 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$318.0896	$954.273 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.5740	$988.723 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.2187	$975.663 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$345.7543	$1,037.263 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$326.1038	$978.313 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.5740	$988.723 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$345.7543	$1,037.263 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9709	$998.913 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$318.0896	$954.273 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	20%	$330.0395	$990.123 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$318.7415	$956.223 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$330.0395	$990.123 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9755	$998.933 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.6872	$980.063 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$350.0073	$1,050.023 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$327.4565	$982.373 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.0395	$990.123 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$350.0073	$1,050.023 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$318.7415	$956.223 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$317.1131	$951.343 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$326.8967	$980.693 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$328.2616	$984.783 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$328.2616	$984.783 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$353.7664	$1,061.303 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.3591	$1,000.083 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.6394	$979.923 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$328.2616	$984.783 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$353.7664	$1,061.303 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$317.1131	$951.343 units	Prior authorization Quantity limit 3 per 28 days

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

Missouri — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$316.6666	$950.003 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.5389	$988.623 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.5389	$988.623 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$327.1676	$981.503 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$351.6158	$1,054.853 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$327.2447	$981.733 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$351.6158	$1,054.853 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.5389	$988.623 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.5335	$1,000.603 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$316.6666	$950.003 units	Prior authorization Quantity limit 3 per 28 days

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

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$316.7222	$950.173 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$327.7579	$983.273 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$327.7579	$983.273 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$324.7289	$974.193 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.3212	$972.963 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$351.2542	$1,053.763 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$327.7579	$983.273 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$351.2542	$1,053.763 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.1398	$999.423 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$316.7222	$950.173 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	20%	$329.0401	$987.123 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$314.3209	$942.963 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.0401	$987.123 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$352.9276	$1,058.783 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.0647	$999.193 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$325.6030	$976.813 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.5510	$976.653 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.0401	$987.123 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$352.9276	$1,058.783 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$314.3209	$942.963 units	Prior authorization Quantity limit 3 per 28 days

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

Colorado — 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	3Preferred Brand	25%	20%	$329.9401	$989.823 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$323.2829	$969.853 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.9401	$989.823 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$329.1226	$987.373 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$327.7420	$983.233 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$352.0194	$1,056.063 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.9401	$989.823 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$352.0194	$1,056.063 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.4350	$1,000.313 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$323.2829	$969.853 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$322.9564	$968.873 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$333.7492	$1,001.253 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$330.2823	$990.853 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$330.2823	$990.853 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$349.9501	$1,049.853 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$333.2314	$999.693 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$349.9501	$1,049.853 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.2823	$990.853 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.0202	$999.063 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$322.9564	$968.873 units	Prior authorization Quantity limit 3 per 28 days

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

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$330.4536	$991.363 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$317.7689	$953.313 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$330.4536	$991.363 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$328.9265	$986.783 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$351.4333	$1,054.303 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$329.4675	$988.403 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$351.4333	$1,054.303 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.4536	$991.363 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9213	$998.763 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$317.7689	$953.313 units	Prior authorization Quantity limit 3 per 28 days

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

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$320.0906	$960.273 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$325.9543	$977.863 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$328.5083	$985.523 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$328.5083	$985.523 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$349.7882	$1,049.363 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$325.5034	$976.513 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$328.5083	$985.523 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$349.7882	$1,049.363 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.3542	$1,000.063 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$320.0906	$960.273 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	20%	$327.8583	$983.573 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$327.8583	$983.573 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$319.1935	$957.583 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.1764	$999.533 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$322.8555	$968.573 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$349.6556	$1,048.973 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$327.8583	$983.573 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$323.7702	$971.313 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$349.6556	$1,048.973 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$319.1935	$957.583 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$316.7863	$950.363 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$327.3837	$982.153 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$329.4739	$988.423 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$329.4739	$988.423 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$350.5164	$1,051.553 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$350.5164	$1,051.553 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$329.4739	$988.423 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.0028	$999.013 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$316.7863	$950.363 units	Prior authorization Quantity limit 3 per 28 days

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

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$316.2073	$948.623 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$330.8091	$992.433 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$330.8091	$992.433 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$349.7716	$1,049.313 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$330.8091	$992.433 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$349.7716	$1,049.313 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$328.5237	$985.573 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9988	$999.003 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$316.2073	$948.623 units	Prior authorization Quantity limit 3 per 28 days

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

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$344.5993	$1,033.803 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$346.9095	$1,040.733 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	19%	$328.5784	$985.743 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$328.5784	$985.743 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$344.7667	$1,034.303 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$344.7667	$1,034.303 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$328.5784	$985.743 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$334.4425	$1,003.333 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$344.5993	$1,033.803 units	Prior authorization Quantity limit 3 per 28 days

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

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$346.5636	$1,039.693 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$332.0021	$996.013 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.7745	$1,001.323 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$312.7920	$938.383 units	Prior authorization Quantity limit 3 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$332.0021	$996.013 units	Prior authorization Quantity limit 3 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$332.0021	$996.013 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$346.5636	$1,039.693 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$312.7920	$938.383 units	Prior authorization Quantity limit 3 per 28 days

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

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$321.7595	$965.283 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$321.7572	$965.273 units	Prior authorization Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$346.9714	$1,040.913 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$357.6975	$1,073.093 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$347.5006	$1,042.503 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$349.3530	$1,048.063 units	Prior authorization Quantity limit 3 per 28 days

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

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	3Preferred Brand	25%	25%	$385.9041	$1,157.713 units	Prior authorization Quantity limit 3 per 28 days

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

OZEMPIC .68 mg/mL Injection, Solution

Coverage by region

Plan-by-plan detail