OZEMPIC 2.68 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%	$328.0483	$984.143 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$311.2456	$933.743 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%	$328.0483	$984.143 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$321.3244	$963.973 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%	$337.9591	$1,013.883 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%	$347.9829	$1,043.953 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$321.3358	$964.013 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	$328.0483	$984.143 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%	$347.9829	$1,043.953 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%	$337.9591	$1,013.883 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9127	$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	$311.2456	$933.743 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%	$328.0027	$984.013 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.4724	$940.423 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%	$328.0027	$984.013 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9543	$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%	$347.0608	$1,041.183 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$322.1857	$966.563 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$322.2006	$966.603 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%	$347.0608	$1,041.183 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	$328.0027	$984.013 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%	$323.0709	$969.213 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%	$321.7710	$965.313 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	$313.4724	$940.423 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%	$315.8868	$947.663 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%	$329.0048	$987.013 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%	$329.0048	$987.013 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%	$351.3956	$1,054.193 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.4767	$979.433 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%	$342.0130	$1,026.043 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$326.8931	$980.683 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	$329.0048	$987.013 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%	$351.3956	$1,054.193 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	$342.0130	$1,026.043 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9477	$998.843 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	$315.8868	$947.663 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%	$328.6075	$985.823 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$316.8496	$950.553 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%	$328.6075	$985.823 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%	$351.1602	$1,053.483 units	Prior authorization Quantity limit 3 per 28 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$340.9787	$1,022.943 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.3891	$976.173 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$326.3023	$978.913 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	$328.6075	$985.823 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%	$351.1602	$1,053.483 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	$340.9787	$1,022.943 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9855	$998.963 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	$316.8496	$950.553 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.

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%	$315.4356	$946.313 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$323.7816	$971.343 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%	$329.2081	$987.623 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%	$329.2081	$987.623 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%	$348.1702	$1,044.513 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$323.2952	$969.893 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%	$348.1702	$1,044.513 units	Prior authorization Quantity limit 3 per 28 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$328.0531	$984.163 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	$329.2081	$987.623 units	Prior authorization Quantity limit 3 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$328.0531	$984.163 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9452	$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	$315.4356	$946.313 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.

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%	$316.0541	$948.163 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%	$331.6723	$995.023 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%	$331.6723	$995.023 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%	$352.5356	$1,057.613 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$327.1424	$981.433 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%	$339.5665	$1,018.703 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%	$352.5356	$1,057.613 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$327.3986	$982.203 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	$331.6723	$995.023 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%	$334.5986	$1,003.803 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9679	$998.903 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	$316.0541	$948.163 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%	$315.6824	$947.053 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$323.4950	$970.493 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%	$327.5934	$982.783 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%	$327.5934	$982.783 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9114	$998.733 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$323.0344	$969.103 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%	$351.9875	$1,055.963 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	$327.5934	$982.783 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%	$351.9875	$1,055.963 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$332.9114	$998.733 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.2739	$999.823 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	$315.6824	$947.053 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%	$315.0477	$945.143 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%	$328.1726	$984.523 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%	$328.1726	$984.523 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.9493	$974.853 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%	$350.1624	$1,050.493 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%	$340.5562	$1,021.673 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.0526	$975.163 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%	$350.1624	$1,050.493 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	$328.1726	$984.523 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%	$334.5729	$1,003.723 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9770	$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	$315.0477	$945.143 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.

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%	$342.6977	$1,028.093 units	Prior authorization Quantity limit 3 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$342.4498	$1,027.353 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$328.7082	$986.123 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$322.6031	$967.813 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%	$329.4374	$988.313 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%	$329.4374	$988.313 units	Prior authorization Quantity limit 3 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$342.4498	$1,027.353 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%	$349.8258	$1,049.483 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	$329.4374	$988.313 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%	$349.8258	$1,049.483 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$334.8417	$1,004.533 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	$322.6031	$967.813 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%	$324.8415	$974.523 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.7490	$941.253 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.8582	$974.573 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%	$329.1462	$987.443 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%	$347.6219	$1,042.873 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%	$329.1462	$987.443 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%	$347.6219	$1,042.873 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	$329.1462	$987.443 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%	$335.5614	$1,006.683 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%	$335.5614	$1,006.683 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9452	$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	$313.7490	$941.253 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%	$329.5391	$988.623 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%	$326.9144	$980.743 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$312.7606	$938.283 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9227	$998.773 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%	$347.9082	$1,043.723 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%	$329.5391	$988.623 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	$329.5391	$988.623 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.2681	$975.803 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%	$347.9082	$1,043.723 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	$326.9144	$980.743 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	$312.7606	$938.283 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%	$314.5489	$943.653 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%	$329.6394	$988.923 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%	$329.6394	$988.923 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.0867	$975.263 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%	$349.4333	$1,048.303 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%	$349.4333	$1,048.303 units	Prior authorization Quantity limit 3 per 28 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$329.5500	$988.653 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	$329.6394	$988.923 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.9113	$977.733 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.0051	$999.023 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	$314.5489	$943.653 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%	$339.2814	$1,017.843 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%	$326.9480	$980.843 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$339.0693	$1,017.213 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%	$326.9480	$980.843 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$347.0222	$1,041.073 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%	$346.2402	$1,038.723 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	$326.9480	$980.843 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%	$346.2402	$1,038.723 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$347.0170	$1,041.053 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%	$339.6536	$1,018.963 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	$339.0693	$1,017.213 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%	$328.5080	$985.523 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%	$348.7875	$1,046.363 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$321.0093	$963.033 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%	$328.5080	$985.523 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.8300	$1,001.493 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.1592	$972.483 units	Prior authorization Quantity limit 3 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$343.9768	$1,031.933 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	$328.5080	$985.523 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$324.3453	$973.043 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%	$348.7875	$1,046.363 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	$321.0093	$963.033 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%	$325.4736	$976.423 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$334.7944	$1,004.383 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%	$328.7382	$986.213 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%	$350.8641	$1,052.593 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%	$328.7382	$986.213 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	$328.7382	$986.213 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%	$350.8641	$1,052.593 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%	$336.9566	$1,010.873 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%	$344.7160	$1,034.153 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.1905	$999.573 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	$325.4736	$976.423 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%	$319.9760	$959.933 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$311.4869	$934.463 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$320.0690	$960.213 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%	$347.1971	$1,041.593 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%	$327.2007	$981.603 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%	$327.2007	$981.603 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%	$347.1971	$1,041.593 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	$327.2007	$981.603 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9686	$998.913 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	$311.4869	$934.463 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.

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%	$328.7669	$986.303 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%	$328.7669	$986.303 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.4761	$940.433 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$324.1312	$972.393 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%	$348.6454	$1,045.943 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.0348	$972.103 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%	$348.6454	$1,045.943 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	$328.7669	$986.303 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9304	$998.793 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	$313.4761	$940.433 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.

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%	$316.7817	$950.353 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%	$329.7312	$989.193 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%	$329.7312	$989.193 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.5000	$973.503 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%	$349.6350	$1,048.903 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	$329.7312	$989.193 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%	$349.6350	$1,048.903 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.9028	$977.713 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.2115	$999.633 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	$316.7817	$950.353 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%	$314.3081	$942.923 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%	$330.2152	$990.653 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%	$330.2152	$990.653 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$343.8834	$1,031.653 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%	$349.6286	$1,048.893 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	$330.2152	$990.653 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%	$349.6286	$1,048.893 units	Prior authorization Quantity limit 3 per 28 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$343.8834	$1,031.653 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9321	$998.803 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	$314.3081	$942.923 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%	$328.9990	$987.003 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$318.4036	$955.213 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%	$328.9990	$987.003 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.5999	$973.803 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%	$345.9454	$1,037.843 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$325.4695	$976.413 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	$328.9990	$987.003 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%	$345.9454	$1,037.843 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9817	$998.953 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	$318.4036	$955.213 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%	$329.6319	$988.903 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$318.9784	$956.943 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%	$329.6319	$988.903 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$332.9649	$998.893 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.9600	$977.883 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%	$350.1149	$1,050.343 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$326.7476	$980.243 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	$329.6319	$988.903 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%	$350.1149	$1,050.343 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	$318.9784	$956.943 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%	$316.8222	$950.473 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$325.3643	$976.093 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%	$327.7771	$983.333 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%	$327.7771	$983.333 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%	$352.5980	$1,057.793 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.3339	$1,000.003 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.1048	$975.313 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	$327.7771	$983.333 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%	$352.5980	$1,057.793 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	$316.8222	$950.473 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%	$316.4150	$949.253 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%	$329.0538	$987.163 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%	$329.0538	$987.163 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$325.7941	$977.383 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%	$351.1397	$1,053.423 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$325.8722	$977.623 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%	$351.1397	$1,053.423 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	$329.0538	$987.163 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.3173	$999.953 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	$316.4150	$949.253 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%	$316.2971	$948.893 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%	$327.4364	$982.313 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%	$327.4364	$982.313 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$323.7411	$971.223 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$323.3488	$970.053 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%	$351.0690	$1,053.213 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	$327.4364	$982.313 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%	$351.0690	$1,053.213 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.1302	$999.393 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	$316.2971	$948.893 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.

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%	$328.4635	$985.393 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$314.3707	$943.113 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%	$328.4635	$985.393 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%	$352.5004	$1,057.503 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.0074	$999.023 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$324.6540	$973.963 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$324.6170	$973.853 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	$328.4635	$985.393 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%	$352.5004	$1,057.503 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	$314.3707	$943.113 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%	$329.5577	$988.673 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$322.2281	$966.683 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%	$329.5577	$988.673 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$327.7594	$983.283 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$326.4849	$979.453 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%	$351.5178	$1,054.553 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	$329.5577	$988.673 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%	$351.5178	$1,054.553 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.3232	$999.973 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	$322.2281	$966.683 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%	$321.8019	$965.413 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$332.1596	$996.483 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%	$330.1705	$990.513 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%	$330.1705	$990.513 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%	$347.8796	$1,043.643 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$331.6502	$994.953 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%	$347.8796	$1,043.643 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	$330.1705	$990.513 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9631	$998.893 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	$321.8019	$965.413 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%	$330.3995	$991.203 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$318.0904	$954.273 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%	$330.3995	$991.203 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$328.1425	$984.433 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%	$350.6946	$1,052.083 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$328.7643	$986.293 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%	$350.6946	$1,052.083 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	$330.3995	$991.203 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9248	$998.773 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	$318.0904	$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.

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%	$320.2232	$960.673 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$325.4617	$976.393 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%	$328.1381	$984.413 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%	$328.1381	$984.413 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%	$349.3923	$1,048.183 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$325.0338	$975.103 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	$328.1381	$984.413 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%	$349.3923	$1,048.183 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$333.3611	$1,000.083 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	$320.2232	$960.673 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%	$327.5315	$982.593 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%	$327.5315	$982.593 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$317.5205	$952.563 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$333.1083	$999.323 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$321.1027	$963.313 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%	$349.4507	$1,048.353 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	$327.5315	$982.593 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$321.9415	$965.823 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%	$349.4507	$1,048.353 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	$317.5205	$952.563 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%	$316.9269	$950.783 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$327.4863	$982.463 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%	$329.4186	$988.263 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%	$329.4186	$988.263 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%	$351.1407	$1,053.423 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%	$351.1407	$1,053.423 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	$329.4186	$988.263 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9651	$998.903 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	$316.9269	$950.783 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.

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%	$316.3738	$949.123 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%	$330.2024	$990.613 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%	$330.2024	$990.613 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%	$349.7483	$1,049.243 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	$330.2024	$990.613 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%	$349.7483	$1,049.243 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$327.4944	$982.483 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.9719	$998.923 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	$316.3738	$949.123 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.

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%	$339.1373	$1,017.413 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$342.1067	$1,026.323 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%	$328.5836	$985.753 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%	$328.5836	$985.753 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%	$345.8830	$1,037.653 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%	$345.8830	$1,037.653 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	$328.5836	$985.753 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$334.0880	$1,002.263 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	$339.1373	$1,017.413 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%	$347.3996	$1,042.203 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%	$332.0922	$996.283 units	Prior authorization Quantity limit 3 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$334.1590	$1,002.483 units	Prior authorization Quantity limit 3 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$313.7270	$941.183 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%	$332.0922	$996.283 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	$332.0922	$996.283 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%	$347.3996	$1,042.203 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	$313.7270	$941.183 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%	$322.0976	$966.293 units	Prior authorization Quantity limit 3 per 28 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$322.0968	$966.293 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%	$346.6890	$1,040.073 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.

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%	$347.1399	$1,041.423 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%	$393.6000	$1,180.803 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.

OZEMPIC 2.68 mg/mL Injection, Solution

Coverage by region

Plan-by-plan detail