PIRFENIDONE 801 mg Tablet, Film Coated

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

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10.8589	$97.739 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.4592	$103.139 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$14.7180	$132.469 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9.5489	$85.949 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$47.9766	$431.799 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$9.5789	$86.219 units	Prior authorization Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$14.7180	$132.469 units	Prior authorization 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.1997	$433.809 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.8219	$61.409 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8925	$476.039 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8925	$476.039 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$8.1256	$73.139 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$57.0942	$5,138.4890 units	Prior authorization Quantity limit 93 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$57.1004	$5,139.0490 units	Prior authorization Quantity limit 93 per 31 days

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

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.4831	$103.359 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6421	$59.789 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.8481	$466.639 units	Prior authorization Quantity limit 9 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.1770	$100.599 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.1742	$433.579 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.8481	$466.639 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6571	$59.919 units	Prior authorization Quantity limit 9 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$11.1770	$100.599 units	Prior authorization 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.5988	$104.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.7248	$60.529 units	Prior authorization Quantity limit 9 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$6.9314	$62.389 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9237	$476.319 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9237	$476.319 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0470	$432.429 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.7248	$60.529 units	Prior authorization Quantity limit 9 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$6.9314	$62.389 units	Prior authorization 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9276	$476.359 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6140	$59.539 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9276	$476.359 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.2229	$434.019 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6187	$59.579 units	Prior authorization Quantity limit 9 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$4.7973	$431.7690 units	Prior authorization Quantity limit 93 per 31 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$4.7973	$431.7690 units	Prior authorization Quantity limit 93 per 31 days

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

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.3440	$102.109 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.3440	$102.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.1107	$64.009 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9429	$476.499 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.6497	$68.859 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$50.9811	$458.839 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.1107	$64.009 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9429	$476.499 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.2072	$64.869 units	Prior authorization 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.3881	$462.499 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$59.5618	$536.069 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.3881	$462.499 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6047	$59.449 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.1631	$433.479 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6666	$60.009 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$59.5618	$536.069 units	Prior authorization 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.6497	$104.859 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.6165	$104.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9367	$476.439 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.7276	$60.559 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.4415	$435.979 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8.6050	$77.459 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9367	$476.439 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.2416	$65.179 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8.0191	$72.179 units	Prior authorization 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.

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8.7060	$78.359 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8.7060	$78.359 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$49.6527	$446.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$8.7060	$78.359 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$47.9766	$431.799 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6047	$59.449 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6047	$59.449 units	Prior authorization 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.0806	$468.739 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.3409	$102.079 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.6987	$105.299 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.0806	$468.739 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.1540	$433.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.8928	$62.049 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.9533	$62.589 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$12.4917	$1,124.2590 units	Prior authorization Quantity limit 3 per 1 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$12.4917	$1,124.2590 units	Prior authorization Quantity limit 3 per 1 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.4750	$103.279 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$59.9835	$539.859 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.6538	$437.889 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.6397	$68.769 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.6824	$69.149 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$59.9835	$539.859 units	Prior authorization 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.3824	$435.449 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6047	$59.449 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6414	$59.779 units	Prior authorization Quantity limit 9 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$4.8302	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8.6479	$77.839 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.8746	$61.879 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.8746	$61.879 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9.0958	$81.869 units	Prior authorization 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6929	$60.249 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.7180	$438.469 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.6970	$465.279 units	Prior authorization Quantity limit 9 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10.8448	$97.609 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.6970	$465.279 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6929	$60.249 units	Prior authorization 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10.2833	$92.559 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.7423	$60.689 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.8799	$61.929 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$49.2200	$442.989 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$14.3596	$129.249 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$14.5425	$130.889 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.1807	$460.639 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.1807	$460.639 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6997	$60.309 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$47.9766	$431.799 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.7135	$60.429 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8207	$475.399 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.7675	$60.919 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8207	$475.399 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.7675	$60.919 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0415	$432.379 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10.8749	$97.879 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.0850	$63.779 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$49.2499	$443.259 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.2051	$64.859 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization 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, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10.0113	$90.109 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0729	$432.669 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$14.5384	$130.859 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.9332	$62.409 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.0448	$63.409 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$14.5384	$130.859 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$50.7858	$457.079 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.7621	$60.869 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0107	$432.109 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$50.7858	$457.079 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.7939	$61.159 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0042	$432.049 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.0138	$468.129 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$8.3154	$74.849 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.0138	$468.129 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$8.6434	$77.799 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8639	$475.789 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.9174	$62.269 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.9185	$440.279 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8639	$475.789 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.9174	$62.269 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$9.1221	$82.109 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.2051	$64.859 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$47.9766	$431.799 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.2051	$64.859 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8363	$475.539 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.8363	$475.539 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.4919	$67.439 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$47.9766	$431.799 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.4919	$67.439 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.5103	$103.599 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.5103	$103.599 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6711	$60.049 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.1638	$433.479 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6711	$60.049 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0847	$432.769 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.0645	$63.589 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.8169	$70.359 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.9341	$467.419 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.6929	$69.249 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.9341	$467.419 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.1335	$433.209 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.8055	$70.259 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.6194	$473.579 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.8889	$71.009 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.6194	$473.579 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$47.9766	$431.799 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.8889	$71.009 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.4160	$102.749 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.4160	$102.749 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.7532	$465.789 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.7056	$60.359 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.7532	$465.789 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.4722	$436.259 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.7600	$60.849 units	Prior authorization 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.6968	$105.279 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.6968	$105.279 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.0141	$432.139 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.2075	$460.879 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6171	$59.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$51.2075	$460.879 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6171	$59.559 units	Prior authorization 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$21.8992	$197.099 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$21.8992	$197.099 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$55.8083	$502.279 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$7.5468	$67.929 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$49.5002	$445.509 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$7.6191	$68.579 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$11.7100	$105.399 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$10.6249	$95.629 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6824	$60.149 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.2836	$434.559 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$6.6824	$60.149 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.0282	$468.259 units	Prior authorization 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$13.1365	$118.239 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$54.0655	$486.599 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$13.1040	$117.949 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$13.0872	$117.789 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$73.6751	$663.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$13.1697	$118.539 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$6.6047	$59.449 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$48.8356	$439.529 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$102.7300	$924.579 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$102.7300	$924.579 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$24.1200	$217.089 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$8.1129	$73.029 units	Prior authorization 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 — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$52.9500	$476.559 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$10.1439	$91.309 units	Prior authorization 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	5Specialty Tier	25%	25%	$13.8608	$124.759 units	Prior authorization 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	5Specialty Tier	25%	25%	$13.8608	$124.759 units	Prior authorization 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	5Specialty Tier	25%	25%	$13.8608	$124.759 units	Prior authorization 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	5Specialty Tier	25%	25%	$13.8608	$124.759 units	Prior authorization 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.

Coverage by region

Plan-by-plan detail