LOKELMA 5 g/5g Powder, For Suspension (Sodium Zirconium Cyclosilicate) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Kansas	11 of 12	3–4	$45.00	6 of 11 plans
Connecticut, Massachusetts, Rhode Island and Vermont	10 of 11	3–4	$30.00	6 of 10 plans
New Jersey	10 of 12	3–4	$45.00	6 of 10 plans
Pennsylvania and West Virginia	10 of 12	3–4	$45.00	8 of 10 plans
North Carolina	10 of 12	3–4	$45.00	6 of 10 plans
Florida	10 of 10	3–4	$45.00	6 of 10 plans
Alabama and Tennessee	10 of 12	3–4	$45.00	6 of 10 plans
Michigan	10 of 12	3–4	$45.00	8 of 10 plans
Illinois	10 of 12	3–4	$45.00	6 of 10 plans
Arkansas	10 of 12	3–4	$45.00	6 of 10 plans
Texas	10 of 12	3–4	$45.00	6 of 10 plans
New Mexico	10 of 11	3–4	$45.00	6 of 10 plans
California	10 of 12	3–4	$45.00	6 of 10 plans
South Carolina	9 of 11	3–4	$45.00	7 of 9 plans
Oklahoma	9 of 11	3–4	$45.00	5 of 9 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	9 of 11	3–4	$45.00	6 of 9 plans
Maine and New Hampshire	8 of 9	3–4	$45.00	6 of 8 plans
New York	8 of 10	3–4	$45.00	6 of 8 plans
Delaware, DC and Maryland	8 of 10	3–4	$45.00	6 of 8 plans
Virginia	8 of 9	3–4	$45.00	6 of 8 plans
Georgia	8 of 10	3–4	$45.00	6 of 8 plans
Ohio	8 of 10	3–4	$45.00	6 of 8 plans
Indiana and Kentucky	8 of 10	3–4	$45.00	6 of 8 plans
Wisconsin	8 of 10	3–4	$45.00	6 of 8 plans
Missouri	8 of 10	3–4	$45.00	6 of 8 plans
Mississippi	8 of 10	3–4	$45.00	6 of 8 plans
Louisiana	8 of 10	3–4	$45.00	6 of 8 plans
Colorado	8 of 10	3–4	$45.00	6 of 8 plans
Arizona	8 of 10	3–4	$45.00	6 of 8 plans
Nevada	8 of 10	3–4	$45.00	6 of 8 plans
Oregon and Washington	8 of 10	3–4	$45.00	6 of 8 plans
Idaho and Utah	8 of 10	3–4	$45.00	6 of 8 plans
Hawaii	8 of 8	3–4	$45.00	6 of 8 plans
Alaska	8 of 9	3–4	$45.00	6 of 8 plans
American Samoa	1 of 1	4	—	1 of 1 plans
Guam	1 of 1	4	—	1 of 1 plans
Northern Mariana Islands	1 of 1	4	—	1 of 1 plans
Puerto Rico	1 of 3	4	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	4	—	1 of 1 plans

Kansas — 11 plans, 6 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%	$31.2562	—	None
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$31.2520	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.6436	—	None
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.6436	—	None
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.4039	$85.213 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4039	$85.213 units	Quantity limit 3 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$31.2520	—	None
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8477	$2,865.3896 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4039	$85.213 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$30.1029	$270.939 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$30.1029	$270.939 units	Quantity limit 9 per 30 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 — 10 plans, 6 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%	$28.3657	$85.103 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.9793	—	None
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$28.2440	—	None
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.9793	—	None
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.7678	$2,857.7196 units	Quantity limit 96 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$28.3657	$85.103 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3657	$85.103 units	Quantity limit 3 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$28.2440	—	None
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$30.0393	$270.359 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$30.0393	$270.359 units	Quantity limit 9 per 30 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 Jersey — 10 plans, 6 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%	$28.1828	$84.553 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.7212	—	None
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.7212	—	None
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$28.1828	$84.553 units	Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$30.4594	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8200	$2,862.7296 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.1828	$84.553 units	Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$30.4594	—	None
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$29.8664	$268.809 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$29.8664	$268.809 units	Quantity limit 9 per 30 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 — 10 plans, 8 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%	$28.2429	$84.733 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.9856	—	None
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.9856	—	None
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2429	$84.733 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.8063	$2,861.4096 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2429	$84.733 units	Quantity limit 3 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$27.7989	$2,501.9090 units	Prior authorization Quantity limit 93 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.6952	$2,492.5790 units	Prior authorization Quantity limit 93 per 31 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$29.8767	$268.899 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$29.8767	$268.899 units	Quantity limit 9 per 30 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 — 10 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.3238	—	None
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.3238	—	None
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3778	$85.133 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3778	$85.133 units	Quantity limit 3 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$30.9479	—	None
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7818	$2,859.0596 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3778	$85.133 units	Quantity limit 3 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$30.9479	—	None
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$30.4260	$273.839 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$30.4260	$273.839 units	Quantity limit 9 per 30 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, 6 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%	$26.8544	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.8544	—	None
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2219	$84.673 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.2219	$84.673 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8119	$2,861.9496 units	Quantity limit 96 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$30.4710	—	None
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2219	$84.673 units	Quantity limit 3 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$30.4710	—	None
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$30.0905	$270.819 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$30.0905	$270.819 units	Quantity limit 9 per 30 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 — 10 plans, 6 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%	$28.0110	$84.033 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.7189	—	None
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.7189	—	None
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.0110	$84.033 units	Quantity limit 3 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$30.3756	—	None
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8138	$2,862.1296 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.0110	$84.033 units	Quantity limit 3 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	3Preferred Brand	$47.00	$94.00	$30.3756	—	None
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$29.9030	$269.139 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$29.9030	$269.139 units	Quantity limit 9 per 30 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 — 10 plans, 8 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%	$27.1974	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1974	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3907	$85.173 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3907	$85.173 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7924	$2,860.0796 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3907	$85.173 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$30.0303	$270.279 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$30.0303	$270.279 units	Quantity limit 9 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$28.3762	$255.399 units	Quantity limit 27 per 90 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	4Non-Preferred Drug	27%	27%	$28.3762	$255.399 units	Quantity limit 27 per 90 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 — 10 plans, 6 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%	$27.2880	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.2880	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3894	$85.173 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3894	$85.173 units	Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$30.5468	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8194	$2,862.6696 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3894	$85.173 units	Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$30.2552	—	None
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$30.5906	$275.329 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$30.5906	$275.329 units	Quantity limit 9 per 30 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 — 10 plans, 6 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%	$26.8557	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.8557	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.1479	$84.443 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.1479	$84.443 units	Quantity limit 3 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$28.7195	—	None
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8200	$2,862.7296 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.1479	$84.443 units	Quantity limit 3 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$28.7195	—	None
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$30.1187	$271.079 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$30.1187	$271.079 units	Quantity limit 9 per 30 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 — 10 plans, 6 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%	$27.0497	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.0497	—	None
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2386	$84.723 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.2386	$84.723 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8087	$2,861.6496 units	Quantity limit 96 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$30.2455	—	None
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2386	$84.723 units	Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7787	—	None
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$30.1814	$271.639 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.1814	$271.639 units	Quantity limit 9 per 30 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 — 10 plans, 6 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%	$28.6765	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$28.6765	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3144	$84.943 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3144	$84.943 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3144	$84.943 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8219	$2,862.9096 units	Quantity limit 96 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	3Preferred Brand	14%	14%	$30.0412	—	None
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$31.0957	—	None
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$30.4040	$273.649 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.4040	$273.649 units	Quantity limit 9 per 30 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 — 10 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.8900	—	None
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.8900	—	None
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8138	$2,862.1296 units	Quantity limit 96 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$28.2501	$84.753 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.2501	$84.753 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2501	$84.753 units	Quantity limit 3 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$28.8346	—	None
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$28.8346	—	None
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$29.9872	$269.889 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$29.9872	$269.889 units	Quantity limit 9 per 30 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 — 9 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1872	—	None
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1872	—	None
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3940	$85.183 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$28.3940	$85.183 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8135	$2,862.1096 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3940	$85.183 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$30.1968	$271.779 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.1968	$271.779 units	Quantity limit 9 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$28.4771	$256.299 units	Quantity limit 9 per 30 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 — 9 plans, 5 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%	$30.1875	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.2001	$84.603 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$28.5019	—	None
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$28.5019	—	None
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2001	$84.603 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2001	$84.603 units	Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$30.1599	—	None
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$29.9173	$269.269 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$29.9173	$269.269 units	Quantity limit 9 per 30 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 — 9 plans, 6 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%	$28.4020	$85.213 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.7762	—	None
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.7762	—	None
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4020	$85.213 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.8754	$2,868.0496 units	Quantity limit 96 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$30.8915	—	None
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4020	$85.213 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$30.1633	$271.479 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$30.1633	$271.479 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$27.4817	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4817	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.4234	$85.273 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4234	$85.273 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7864	$2,859.4996 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4234	$85.273 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$30.3217	$272.909 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$30.3217	$272.909 units	Quantity limit 9 per 30 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 — 8 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.6864	—	None
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$26.6864	—	None
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8059	$2,861.3796 units	Quantity limit 96 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.0861	$84.263 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$28.0861	$84.263 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.0861	$84.263 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$29.8753	$268.889 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$29.8753	$268.889 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.2334	$84.703 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2334	$84.703 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.0475	—	None
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.0475	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7714	$2,858.0596 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2334	$84.703 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$29.9034	$269.139 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$29.9034	$269.139 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$27.2535	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.2535	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.4760	$85.433 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4760	$85.433 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8017	$2,860.9696 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4760	$85.433 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$30.1040	$270.949 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.1040	$270.949 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$27.4676	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4676	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.4256	$85.283 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4256	$85.283 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8045	$2,861.2396 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4256	$85.283 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$30.3526	$273.179 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$30.3526	$273.179 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.3090	$84.933 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4735	—	None
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4735	—	None
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3090	$84.933 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7679	$2,857.7296 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3090	$84.933 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$30.2892	$272.609 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$30.2892	$272.609 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.4068	$85.223 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4161	—	None
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4161	—	None
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4068	$85.223 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.8087	$2,861.6496 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4068	$85.223 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$30.1923	$271.739 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$30.1923	$271.739 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$27.3031	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.3031	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.2938	$84.883 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2938	$84.883 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.7760	$2,858.5096 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2938	$84.883 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$30.5603	$275.049 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$30.5603	$275.049 units	Quantity limit 9 per 30 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 — 8 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1821	—	None
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1821	—	None
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.2794	$84.843 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2794	$84.843 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8110	$2,861.8696 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2794	$84.843 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$30.4164	$273.759 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.4164	$273.759 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$27.5454	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.5454	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3178	$84.953 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3178	$84.953 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3178	$84.953 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8085	$2,861.6296 units	Quantity limit 96 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$30.2023	$271.829 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$30.2023	$271.829 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.2861	$84.863 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1233	—	None
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.1233	—	None
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2861	$84.863 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.8073	$2,861.5096 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2861	$84.863 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$30.4145	$273.739 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$30.4145	$273.739 units	Quantity limit 9 per 30 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 — 8 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.9005	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.4675	$85.403 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.9005	—	None
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4675	$85.403 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7908	$2,859.9296 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4675	$85.403 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$30.4491	$274.049 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$30.4491	$274.049 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.0956	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$28.0956	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$28.3878	$85.163 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3878	$85.163 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.7884	$2,859.6996 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3878	$85.163 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$30.2573	$272.329 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.2573	$272.329 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.3921	$85.183 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.3102	—	None
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.3102	—	None
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$28.3921	$85.183 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8052	$2,861.3096 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3921	$85.183 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$30.3867	$273.489 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$30.3867	$273.489 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$27.4874	—	None
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.4874	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$28.3660	$85.103 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.3660	$85.103 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$29.8011	$2,860.9196 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.3660	$85.103 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$30.1585	$271.439 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$30.1585	$271.439 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.2590	$84.783 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.2080	—	None
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.2590	$84.783 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.2080	—	None
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.8148	$2,862.2296 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.2590	$84.783 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$30.0093	$270.089 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$30.0093	$270.089 units	Quantity limit 9 per 30 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, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$28.6141	$85.843 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$29.8165	$2,862.3896 units	Quantity limit 96 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.5170	—	None
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$27.5170	—	None
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.6141	$85.843 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.6141	$85.843 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$29.8691	$268.829 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$29.8691	$268.829 units	Quantity limit 9 per 30 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 — 8 plans, 6 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%	$28.0843	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	19%	$28.4741	$85.423 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$28.4741	$85.423 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$28.0843	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$30.1344	$2,892.9096 units	Quantity limit 96 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$28.4741	$85.423 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$30.7820	$277.049 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$30.7820	$277.049 units	Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$30.8913	$278.029 units	Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$30.8913	$278.029 units	Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$30.8913	$278.029 units	Quantity limit 9 per 30 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 — 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)$145.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$29.9098	$269.199 units	Quantity limit 9 per 30 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	4Non-Preferred Drug	25%	25%	$30.8913	$278.029 units	Quantity limit 9 per 30 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.

LOKELMA 5 g/5g Powder, For Suspension

Coverage by region

Plan-by-plan detail