OXYCODONE AND ACETAMINOPHEN 10/325 mg Tablet (Oxycodone Hydrochloride And Acetaminophen) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	3–4	$45.00	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	3–4	$45.00	12 of 12 plans
North Carolina	12 of 12	3–4	$45.00	12 of 12 plans
Alabama and Tennessee	12 of 12	3–4	$45.00	12 of 12 plans
Michigan	12 of 12	3–4	$45.00	12 of 12 plans
Illinois	12 of 12	3–4	$45.00	12 of 12 plans
Arkansas	12 of 12	3–4	$45.00	12 of 12 plans
Texas	12 of 12	3–4	$45.00	12 of 12 plans
Kansas	12 of 12	3–4	$45.00	12 of 12 plans
California	12 of 12	3–4	$45.00	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	3–4	$30.00	11 of 11 plans
South Carolina	11 of 11	3–4	$45.00	10 of 11 plans
Oklahoma	11 of 11	3–4	$45.00	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	3–4	$45.00	11 of 11 plans
New Mexico	11 of 11	3–4	$45.00	11 of 11 plans
New York	10 of 10	3–4	$45.00	10 of 10 plans
Delaware, DC and Maryland	10 of 10	3–4	$45.00	10 of 10 plans
Georgia	10 of 10	3–4	$45.00	10 of 10 plans
Florida	10 of 10	3–4	$45.00	10 of 10 plans
Ohio	10 of 10	3–4	$45.00	10 of 10 plans
Indiana and Kentucky	10 of 10	3–4	$45.00	10 of 10 plans
Wisconsin	10 of 10	3–4	$45.00	10 of 10 plans
Missouri	10 of 10	3–4	$45.00	10 of 10 plans
Mississippi	10 of 10	3–4	$45.00	10 of 10 plans
Louisiana	10 of 10	3–4	$45.00	10 of 10 plans
Colorado	10 of 10	3–4	$45.00	10 of 10 plans
Arizona	10 of 10	3–4	$45.00	10 of 10 plans
Nevada	10 of 10	3–4	$45.00	10 of 10 plans
Oregon and Washington	10 of 10	3–4	$45.00	10 of 10 plans
Idaho and Utah	10 of 10	3–4	$45.00	10 of 10 plans
Maine and New Hampshire	9 of 9	3–4	$45.00	9 of 9 plans
Virginia	9 of 9	3–4	$45.00	9 of 9 plans
Alaska	9 of 9	3–4	$45.00	9 of 9 plans
Hawaii	8 of 8	3–4	$45.00	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
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.6440	$23.1836 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3229	$11.6236 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4584	$16.5036 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3823	$13.7636 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3243	$11.6736 units	Quantity limit 36 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$0.6018	$10.8318 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3831	$13.7936 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5681	$10.2318 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5690	$10.2418 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3844	$13.8436 units	Quantity limit 36 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$0.6018	$10.8318 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2077	$3.7418 units	Quantity limit 18 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1762	$3.1718 units	Quantity limit 18 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.3162	$11.3836 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.6158	$22.1736 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4810	$17.3236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3164	$11.3936 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3656	$13.1636 units	Quantity limit 36 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$0.2310	$83.16360 units	Prior authorization Quantity limit 372 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2310	$83.16360 units	Prior authorization Quantity limit 372 per 31 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3671	$13.2236 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5925	$10.6718 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5929	$10.6718 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3696	$13.3136 units	Quantity limit 36 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3130	$11.2736 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.8042	$28.9536 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5957	$21.4536 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3870	$13.9336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3130	$11.2736 units	Quantity limit 36 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$0.8136	$14.6418 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6115	$11.0118 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6115	$11.0118 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3893	$14.0136 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3934	$14.1636 units	Quantity limit 36 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.8136	$14.6418 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2105	$3.7918 units	Quantity limit 18 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3168	$11.4036 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7172	$25.8236 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5223	$18.8036 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3847	$13.8536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3168	$11.4036 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3863	$13.9136 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5625	$10.1218 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5625	$10.1218 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3891	$14.0136 units	Quantity limit 36 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$0.7132	$12.8418 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2047	$3.6818 units	Quantity limit 18 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$0.7132	$12.8418 units	Quantity limit 18 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 — 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%	$0.4243	$15.2736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3193	$11.4936 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5829	$20.9836 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3198	$11.5136 units	Quantity limit 36 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2491	$89.68360 units	Quantity limit 372 per 31 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3785	$13.6336 units	Quantity limit 36 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$0.2491	$89.68360 units	Quantity limit 372 per 31 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5415	$9.7518 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5415	$9.7518 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3792	$13.6536 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3804	$13.6936 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2138	$3.8518 units	Quantity limit 18 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.

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3188	$11.4836 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0795	$38.8636 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3196	$11.5136 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.6887	$24.7936 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4207	$15.1536 units	Quantity limit 36 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.8226	$14.8118 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6765	$12.1818 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6737	$12.1318 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4224	$15.2136 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.4253	$15.3136 units	Quantity limit 36 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$0.8377	$15.0818 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2202	$3.9618 units	Quantity limit 18 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 — 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%	$0.5092	$18.3336 units	Quantity limit 36 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.6539	$11.7718 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.6340	$22.8236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3200	$11.5236 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3644	$13.1236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3200	$11.5236 units	Quantity limit 36 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.6539	$11.7718 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4793	$8.6318 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4793	$8.6318 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3669	$13.2136 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3713	$13.3736 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2078	$3.7418 units	Quantity limit 18 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7944	$28.6036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3152	$11.3536 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5575	$20.0736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3152	$11.3536 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3928	$14.1436 units	Quantity limit 36 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.7552	$13.5918 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6539	$11.7718 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6525	$11.7418 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3976	$14.3136 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3945	$14.2036 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2168	$3.9018 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$0.7354	$13.2418 units	Quantity limit 18 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.

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.6820	$24.5536 units	Quantity limit 36 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.8668	$15.6018 units	Quantity limit 18 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3357	$12.0936 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3701	$13.3236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3382	$12.1836 units	Quantity limit 36 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.8275	$14.8918 units	Quantity limit 18 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.8668	$15.6018 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6694	$12.0518 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.6694	$12.0518 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3730	$13.4336 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3781	$13.6136 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2725	$4.9118 units	Quantity limit 18 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 — 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%	$0.5533	$19.9236 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.8148	$29.3336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3206	$11.5436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3217	$11.5836 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3932	$14.1636 units	Quantity limit 36 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.3803	$31.9584 units	Quantity limit 84 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$0.3803	$31.9584 units	Quantity limit 84 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6085	$10.9518 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6108	$10.9918 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2112	$3.8018 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3963	$14.2736 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3943	$14.1936 units	Quantity limit 36 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3180	$5.7218 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1540	$2.7718 units	Quantity limit 18 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3173	$11.4236 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4044	$14.5636 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5289	$19.0436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3175	$11.4336 units	Quantity limit 36 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$0.3180	$5.7218 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4051	$14.5836 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6926	$12.4718 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6939	$12.4918 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.4064	$14.6336 units	Quantity limit 36 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 — 11 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7066	$25.4436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3151	$11.3436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3155	$11.3636 units	Quantity limit 36 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2635	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3773	$13.5836 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5435	$19.5736 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6358	$11.4418 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6358	$11.4418 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.3794	$13.6636 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3831	$13.7936 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2122	$3.8218 units	Quantity limit 18 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7399	$26.6436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3178	$11.4436 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3812	$13.7236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3178	$11.4436 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.5530	$19.9136 units	Quantity limit 36 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.8541	$15.3718 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.8682	$15.6318 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$0.3837	$13.8136 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5173	$9.3118 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.5173	$9.3118 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3880	$13.9736 units	Quantity limit 36 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3224	$11.6136 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2345	$4.2218 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.6879	$24.7636 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3742	$13.4736 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5040	$18.1436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3225	$11.6136 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3759	$13.5336 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5918	$10.6518 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5929	$10.6718 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3790	$13.6436 units	Quantity limit 36 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$0.8667	$15.6018 units	Quantity limit 18 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 — 11 plans, 11 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%	$0.8281	$29.8136 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.3189	$11.4836 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4128	$14.8636 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3193	$11.4936 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6479	$11.6618 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6446	$11.6018 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4168	$15.0036 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.4238	$15.2636 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2203	$3.9718 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.8975	$16.1618 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.8875	$15.9718 units	Quantity limit 18 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 — 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%	$0.4074	$14.6736 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5459	$19.6536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3183	$11.4636 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3186	$11.4736 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3740	$13.4636 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5265	$9.4818 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5286	$9.5118 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2108	$3.7918 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.3745	$13.4836 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.3756	$13.5236 units	Quantity limit 36 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5267	$18.9636 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3137	$11.2936 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7761	$27.9436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3137	$11.2936 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3950	$14.2236 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3962	$14.2636 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3981	$14.3336 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6121	$11.0218 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6134	$11.0418 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2126	$3.8318 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.6528	$23.5036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3149	$11.3436 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3741	$13.4736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3150	$11.3436 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5021	$18.0836 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5881	$10.5918 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5881	$10.5918 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3758	$13.5336 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3787	$13.6336 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2146	$3.8618 units	Quantity limit 18 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, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3159	$11.3736 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4084	$14.7036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3163	$11.3936 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.6986	$12.5718 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6986	$12.5718 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.4120	$14.8336 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4097	$14.7536 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1884	$3.3918 units	Quantity limit 18 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7302	$13.1418 units	Quantity limit 18 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.7302	$13.1418 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.8082	$29.1036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3149	$11.3436 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.6097	$21.9536 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3787	$13.6336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3149	$11.3436 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.3803	$13.6936 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6799	$12.2418 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6799	$12.2418 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3832	$13.8036 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2069	$3.7218 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1920	$3.4618 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7306	$26.3036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3165	$11.3936 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.5453	$19.6336 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3834	$13.8036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3165	$11.3936 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3847	$13.8536 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6227	$11.2118 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6227	$11.2118 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3871	$13.9436 units	Quantity limit 36 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 — 10 plans, 10 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%	$0.6279	$22.6036 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3124	$11.2536 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2047	$3.6818 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.9458	$34.0536 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4198	$15.1136 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3124	$11.2536 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.6127	$11.0318 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6127	$11.0318 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4215	$15.1736 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.4245	$15.2836 units	Quantity limit 36 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7720	$27.7936 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3180	$11.4536 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.5732	$20.6436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3184	$11.4636 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3858	$13.8936 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5840	$10.5118 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.5840	$10.5118 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3883	$13.9836 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3928	$14.1436 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2264	$4.0818 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4758	$17.1336 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5904	$21.2536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3163	$11.3936 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3630	$13.0736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3164	$11.3936 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4252	$7.6518 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4252	$7.6518 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3652	$13.1536 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3690	$13.2836 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2220	$4.0018 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.3145	$11.3236 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2113	$3.8018 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.5123	$18.4436 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7380	$26.5736 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4014	$14.4536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3145	$11.3236 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4029	$14.5036 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4996	$8.9918 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4999	$9.0018 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.4054	$14.5936 units	Quantity limit 36 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.7840	$28.2236 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0970	$39.4936 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.3141	$11.3136 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3897	$14.0336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3142	$11.3136 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6603	$11.8918 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.3928	$14.1436 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6634	$11.9418 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3983	$14.3436 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2353	$4.2418 units	Quantity limit 18 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 — 10 plans, 10 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%	$0.8088	$29.1236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3163	$11.3936 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.1986	$43.1536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3168	$11.4036 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4152	$14.9536 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.7100	$12.7818 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7068	$12.7218 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.4181	$15.0536 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.4232	$15.2436 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2236	$4.0218 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0645	$38.3236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.3148	$11.3336 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.7215	$25.9736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3149	$11.3436 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4100	$14.7636 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4122	$14.8436 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.7161	$12.8918 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7136	$12.8418 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.4159	$14.9736 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2137	$3.8518 units	Quantity limit 18 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 — 10 plans, 10 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	24%	24%	$0.6663	$23.9936 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3178	$11.4436 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.9681	$34.8536 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3735	$13.4536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3180	$11.4536 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5790	$10.4218 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5737	$10.3318 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3754	$13.5136 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3787	$13.6336 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2378	$4.2818 units	Quantity limit 18 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2095	$3.7718 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7696	$27.7136 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3184	$11.4636 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3652	$13.1536 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5807	$20.9136 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3185	$11.4736 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3674	$13.2336 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5024	$9.0418 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3713	$13.3736 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5046	$9.0818 units	Quantity limit 18 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 — 9 plans, 9 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%	$0.6371	$22.9436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3237	$11.6536 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3237	$11.6536 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3959	$14.2536 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.7172	$12.9118 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7163	$12.8918 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3990	$14.3636 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.4045	$14.5636 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2256	$4.0618 units	Quantity limit 18 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3161	$11.3836 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3816	$13.7436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3161	$11.3836 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.6171	$22.2236 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6816	$12.2718 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6814	$12.2718 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3844	$13.8436 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3894	$14.0236 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2197	$3.9518 units	Quantity limit 18 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 — 9 plans, 9 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%	$0.6704	$24.1336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.3344	$12.0436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.3352	$12.0736 units	Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3654	$13.1536 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5880	$10.5818 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.3659	$13.1736 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3668	$13.2036 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5815	$10.4718 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2486	$4.4718 units	Quantity limit 18 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, 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%	$0.3167	$11.4036 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2267	$4.0818 units	Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3620	$13.0336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3173	$11.4236 units	Quantity limit 36 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.3646	$13.1336 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5907	$10.6318 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.5928	$10.6718 units	Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.3694	$13.3036 units	Quantity limit 36 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 — 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%	$0.7644	$27.5236 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.4813	$17.3336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.5637	$20.2936 units	Quantity limit 36 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	3Preferred Brand	25%	25%	$0.5657	$20.3736 units	Quantity limit 36 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	3Preferred Brand	25%	25%	$0.3196	$11.5136 units	Quantity limit 36 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	3Preferred Brand	25%	25%	$0.5657	$20.3736 units	Quantity limit 36 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	3Preferred Brand	25%	25%	$0.3155	$11.3636 units	Quantity limit 36 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.

OXYCODONE AND ACETAMINOPHEN 10/325 mg Tablet

Coverage by region

Plan-by-plan detail