MEMANTINE HYDROCHLORIDE Kit

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	10 of 12	2–4	$0.00	10 of 10 plans
Pennsylvania and West Virginia	10 of 12	2–4	$0.00	8 of 10 plans
North Carolina	10 of 12	2–4	$0.00	10 of 10 plans
Alabama and Tennessee	10 of 12	2–4	$0.00	10 of 10 plans
Michigan	10 of 12	2–3	$0.00	10 of 10 plans
Illinois	10 of 12	2–4	$0.00	10 of 10 plans
Texas	10 of 12	2–4	$0.00	10 of 10 plans
Kansas	10 of 12	2–4	$0.00	10 of 10 plans
South Carolina	9 of 11	2–3	$0.00	8 of 9 plans
Oklahoma	9 of 11	2–4	$0.00	9 of 9 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	9 of 11	2–4	$0.00	9 of 9 plans
New Mexico	9 of 11	2–4	$0.00	9 of 9 plans
California	9 of 12	2–3	$0.00	8 of 9 plans
New York	8 of 10	2–3	$0.00	8 of 8 plans
Delaware, DC and Maryland	8 of 10	2–3	$0.00	8 of 8 plans
Georgia	8 of 10	2–3	$0.00	8 of 8 plans
Florida	8 of 10	2–4	$0.00	8 of 8 plans
Ohio	8 of 10	2–3	$0.00	8 of 8 plans
Indiana and Kentucky	8 of 10	2–3	$0.00	8 of 8 plans
Wisconsin	8 of 10	2–3	$0.00	8 of 8 plans
Missouri	8 of 10	2–3	$0.00	8 of 8 plans
Arkansas	8 of 12	2–3	$0.00	8 of 8 plans
Mississippi	8 of 10	2–3	$0.00	8 of 8 plans
Louisiana	8 of 10	2–3	$0.00	8 of 8 plans
Colorado	8 of 10	2–3	$0.00	8 of 8 plans
Arizona	8 of 10	2–3	$0.00	8 of 8 plans
Nevada	8 of 10	2–3	$0.00	8 of 8 plans
Oregon and Washington	8 of 10	2–3	$0.00	8 of 8 plans
Idaho and Utah	8 of 10	2–3	$0.00	8 of 8 plans
Maine and New Hampshire	7 of 9	2–3	$0.00	7 of 7 plans
Connecticut, Massachusetts, Rhode Island and Vermont	7 of 11	2–3	$0.00	7 of 7 plans
Virginia	7 of 9	2–3	$0.00	7 of 7 plans
Alaska	7 of 9	2–3	$0.00	7 of 7 plans
Hawaii	6 of 8	2–3	$0.00	6 of 6 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 — 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)$4.40/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4102	$40.2098 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4102	$40.2098 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4102	$40.2098 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$4.7989	$38.398 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5317	$4.258 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.7988	$38.398 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.5317	$4.258 units	Prior authorization Quantity limit 98 per 365 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$5.1759	—	Prior authorization
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$5.1759	—	Prior authorization

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

Pennsylvania and West Virginia — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4137	$40.5498 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4137	$40.5498 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4137	$40.5498 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.4980	$3.988 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8134	$38.518 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8129	$38.508 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4980	$3.988 units	Prior authorization Quantity limit 98 per 365 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$4.8439	—	None
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.8148	—	None

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

North Carolina — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4218	$41.3498 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4218	$41.3498 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4218	$41.3498 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4887	$3.918 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8414	$38.738 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$4.8461	$38.778 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4887	$3.918 units	Prior authorization Quantity limit 98 per 365 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$5.2486	—	Prior authorization
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$5.2486	—	Prior authorization

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

Alabama and Tennessee — 10 plans, 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	2Generic	$1.00	$0.00	$0.4186	$41.0298 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4186	$41.0298 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4186	$41.0298 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5036	$4.038 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8121	$38.508 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$4.8241	$38.598 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.5036	$4.038 units	Prior authorization Quantity limit 98 per 365 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$5.2080	—	Prior authorization
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$5.2080	—	Prior authorization

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

Michigan — 10 plans, 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	2Generic	$1.00	$0.00	$0.4089	$40.0798 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4089	$40.0798 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4089	$40.0798 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8006	$38.408 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5054	$4.048 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.7923	$38.348 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.5054	$4.048 units	Prior authorization Quantity limit 98 per 365 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4626	$3.708 units	Prior authorization Quantity limit 98 per 365 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$0.4626	$3.708 units	Prior authorization Quantity limit 98 per 365 days

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

Illinois — 10 plans, 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	2Generic	$1.00	$0.00	$0.4210	$41.2698 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4210	$41.2698 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4210	$41.2698 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4952	$3.968 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8272	$38.628 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4952	$3.968 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8315	$38.658 units	Prior authorization Quantity limit 98 per 365 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$5.1563	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$5.2491	—	Prior authorization

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

Texas — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4198	$41.1498 units	Prior authorization Quantity limit 98 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4198	$41.1498 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4198	$41.1498 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8055	$38.448 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4919	$3.948 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5750	$36.608 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8073	$38.468 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4919	$3.948 units	Prior authorization Quantity limit 98 per 365 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$5.1516	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$5.2420	—	Prior authorization

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 — 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)$15.50/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4402	$43.1498 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4402	$43.1498 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4402	$43.1498 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8801	$39.048 units	Prior authorization Quantity limit 98 per 365 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$5.2759	—	Prior authorization
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4913	$3.938 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4913	$3.938 units	Prior authorization Quantity limit 98 per 365 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.2759	—	Prior authorization
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$5.2759	—	Prior authorization

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

South Carolina — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	2Generic	$2.00	$0.00	$0.4190	$41.0698 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4190	$41.0698 units	Prior authorization Quantity limit 98 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	2Generic	$17.00	$42.50	$0.4760	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4190	$41.0698 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8169	$38.548 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4899	$3.928 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4899	$3.928 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8252	$38.608 units	Prior authorization Quantity limit 98 per 365 days

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

Oklahoma — 9 plans, 9 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	2Generic	$2.00	$0.00	$0.4301	$42.1598 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4301	$42.1598 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4301	$42.1598 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8507	$38.818 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4906	$3.928 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4906	$3.928 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.8508	$38.818 units	Prior authorization Quantity limit 98 per 365 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$5.1621	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$5.1641	—	Prior authorization

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 9 plans, 9 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	2Generic	$1.00	$0.00	$0.4269	$41.8498 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4269	$41.8498 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5853	$36.688 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4269	$41.8498 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5100	$4.088 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8202	$38.568 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8237	$38.598 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.5100	$4.088 units	Prior authorization Quantity limit 98 per 365 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$5.2957	—	Prior authorization

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 — 9 plans, 9 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	2Generic	$1.00	$0.00	$0.4303	$42.1798 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4303	$42.1798 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4303	$42.1798 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8373	$38.708 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.5152	$4.128 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.5152	$4.128 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5702	$36.568 units	Prior authorization Quantity limit 98 per 365 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1779	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$5.3149	—	Prior authorization

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 — 9 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4105	$40.2398 units	Prior authorization Quantity limit 98 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4105	$40.2398 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4105	$40.2398 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8412	$38.738 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8423	$38.748 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5791	$36.638 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4914	$3.938 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4914	$3.938 units	Prior authorization Quantity limit 98 per 365 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$4.6765	—	None

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

New York — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4028	$39.4798 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4028	$39.4798 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4028	$39.4798 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.7938	$38.358 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.7966	$38.378 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5156	$4.128 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.5156	$4.128 units	Prior authorization Quantity limit 98 per 365 days

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

Delaware, DC and Maryland — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4048	$39.6798 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4048	$39.6798 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4048	$39.6798 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$4.7989	$38.398 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4918	$3.938 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.7983	$38.398 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4918	$3.938 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days

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

Georgia — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4224	$41.4098 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4224	$41.4098 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4224	$41.4098 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8292	$38.638 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4927	$3.948 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4927	$3.948 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8493	$38.798 units	Prior authorization Quantity limit 98 per 365 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4124	$40.4298 units	Prior authorization Quantity limit 98 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4124	$40.4298 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4124	$40.4298 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4901	$3.928 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4901	$3.928 units	Prior authorization Quantity limit 98 per 365 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$5.2959	—	Prior authorization
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$5.2959	—	Prior authorization

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

Ohio — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4192	$41.0898 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4192	$41.0898 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4192	$41.0898 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8268	$38.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4946	$3.968 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8338	$38.678 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4946	$3.968 units	Prior authorization Quantity limit 98 per 365 days

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

Indiana and Kentucky — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4338	$42.5198 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4338	$42.5198 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4338	$42.5198 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8581	$38.868 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4972	$3.988 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.8724	$38.988 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4972	$3.988 units	Prior authorization Quantity limit 98 per 365 days

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

Wisconsin — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4274	$41.8998 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4274	$41.8998 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5822	$36.668 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4274	$41.8998 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8449	$38.768 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4870	$3.908 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8405	$38.728 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4870	$3.908 units	Prior authorization Quantity limit 98 per 365 days

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

Missouri — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.4281	$41.9598 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4281	$41.9598 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4281	$41.9598 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8473	$38.788 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5101	$4.088 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.8478	$38.788 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.5101	$4.088 units	Prior authorization Quantity limit 98 per 365 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 — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4356	$42.6998 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4356	$42.6998 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4356	$42.6998 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.7995	$38.408 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.7947	$38.368 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.5048	$4.048 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.5048	$4.048 units	Prior authorization Quantity limit 98 per 365 days

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

Mississippi — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4336	$42.4998 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4336	$42.4998 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4336	$42.4998 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8335	$38.678 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8285	$38.638 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4888	$3.918 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4888	$3.918 units	Prior authorization Quantity limit 98 per 365 days

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

Louisiana — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4311	$42.2598 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4311	$42.2598 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4311	$42.2598 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.4885	$3.918 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.7741	$38.198 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.7733	$38.198 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4885	$3.918 units	Prior authorization Quantity limit 98 per 365 days

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

Colorado — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4318	$42.3298 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4318	$42.3298 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4318	$42.3298 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.8627	$38.908 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8400	$38.728 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5828	$36.668 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.4881	$3.908 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4881	$3.908 units	Prior authorization Quantity limit 98 per 365 days

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

Arizona — 8 plans, 8 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	2Generic	$3.00	$0.00	$0.4229	$41.4498 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4229	$41.4498 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4229	$41.4498 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8550	$38.848 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4980	$3.988 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8479	$38.788 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5807	$36.658 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4980	$3.988 units	Prior authorization Quantity limit 98 per 365 days

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

Nevada — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4286	$42.0098 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4286	$42.0098 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4286	$42.0098 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8527	$38.828 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.4854	$3.888 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$4.8612	$38.898 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4854	$3.888 units	Prior authorization Quantity limit 98 per 365 days

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

Oregon and Washington — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4159	$40.7698 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4159	$40.7698 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4159	$40.7698 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$4.8252	$38.608 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5627	$4.508 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$4.8210	$38.578 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5740	$36.598 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.5627	$4.508 units	Prior authorization Quantity limit 98 per 365 days

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

Idaho and Utah — 8 plans, 8 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	2Generic	$1.00	$0.00	$0.4180	$40.9698 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4180	$40.9698 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4180	$40.9698 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.7523	$38.028 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4937	$3.958 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.7618	$38.098 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4937	$3.958 units	Prior authorization Quantity limit 98 per 365 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 — 7 plans, 7 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	2Generic	$1.00	$0.00	$0.4204	$41.2098 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4204	$41.2098 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4204	$41.2098 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8495	$38.808 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4874	$3.908 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4874	$3.908 units	Prior authorization Quantity limit 98 per 365 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 — 7 plans, 7 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	2Generic	$1.00	$0.00	$0.4142	$40.5998 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4142	$40.5998 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4142	$40.5998 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5195	$4.168 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$4.8648	$38.928 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.5195	$4.168 units	Prior authorization Quantity limit 98 per 365 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 — 7 plans, 7 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	2Generic	$1.00	$0.00	$0.4301	$42.1598 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4301	$42.1598 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4301	$42.1598 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4871	$3.908 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4871	$3.908 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$4.8755	$39.008 units	Prior authorization Quantity limit 98 per 365 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 — 7 plans, 7 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	2Generic	$3.00	$0.00	$0.3959	$38.8098 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.3959	$38.8098 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.3959	$38.8098 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.6500	$37.208 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.4929	$3.948 units	Prior authorization Quantity limit 98 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4929	$3.948 units	Prior authorization Quantity limit 98 per 365 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	2Generic	$4.00	$0.00	$0.4167	$40.8498 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5764	$36.618 units	Prior authorization Quantity limit 98 per 365 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4167	$40.8498 units	Prior authorization Quantity limit 98 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4167	$40.8498 units	Prior authorization Quantity limit 98 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.4858	$3.898 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4858	$3.898 units	Prior authorization Quantity limit 98 per 365 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%	$4.8189	$38.558 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$4.8189	$38.558 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.7668	$6.138 units	Prior authorization Quantity limit 98 per 365 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%	$0.8911	$7.138 units	Prior authorization Quantity limit 98 per 365 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%	$0.8911	$7.138 units	Prior authorization Quantity limit 98 per 365 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%	$0.8911	$7.138 units	Prior authorization Quantity limit 98 per 365 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%	$0.8911	$7.138 units	Prior authorization Quantity limit 98 per 365 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