SPIRIVA RESPIMAT 3.124 ug Spray, Metered (Tiotropium Bromide Inhalation Spray) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	11 of 12	3–4	$45.00	11 of 11 plans
Pennsylvania and West Virginia	11 of 12	3–4	$45.00	11 of 11 plans
North Carolina	11 of 12	3–4	$45.00	11 of 11 plans
Alabama and Tennessee	11 of 12	3–4	$45.00	11 of 11 plans
Michigan	11 of 12	3–4	$45.00	11 of 11 plans
Illinois	11 of 12	3–4	$45.00	11 of 11 plans
Texas	11 of 12	3–4	$45.00	11 of 11 plans
Oklahoma	11 of 11	3–4	$45.00	11 of 11 plans
Kansas	11 of 12	3–4	$45.00	11 of 11 plans
California	11 of 12	3–4	$45.00	11 of 11 plans
South Carolina	10 of 11	3–4	$45.00	9 of 10 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	10 of 11	3–4	$45.00	10 of 10 plans
New Mexico	10 of 11	3–4	$45.00	10 of 10 plans
New York	9 of 10	3–4	$45.00	9 of 9 plans
Delaware, DC and Maryland	9 of 10	3–4	$45.00	9 of 9 plans
Georgia	9 of 10	3–4	$45.00	9 of 9 plans
Florida	9 of 10	3–4	$45.00	9 of 9 plans
Ohio	9 of 10	3–4	$45.00	9 of 9 plans
Indiana and Kentucky	9 of 10	3–4	$45.00	9 of 9 plans
Wisconsin	9 of 10	3–4	$45.00	9 of 9 plans
Missouri	9 of 10	3–4	$45.00	9 of 9 plans
Arkansas	9 of 12	3–4	$45.00	9 of 9 plans
Mississippi	9 of 10	3–4	$45.00	9 of 9 plans
Louisiana	9 of 10	3–4	$45.00	9 of 9 plans
Colorado	9 of 10	3–4	$45.00	9 of 9 plans
Arizona	9 of 10	3–4	$45.00	9 of 9 plans
Nevada	9 of 10	3–4	$45.00	9 of 9 plans
Oregon and Washington	9 of 10	3–4	$45.00	9 of 9 plans
Idaho and Utah	9 of 10	3–4	$45.00	9 of 9 plans
Maine and New Hampshire	8 of 9	3–4	$45.00	8 of 8 plans
Connecticut, Massachusetts, Rhode Island and Vermont	8 of 11	3–4	$45.00	8 of 8 plans
Virginia	8 of 9	3–4	$45.00	8 of 8 plans
Alaska	8 of 9	3–4	$45.00	8 of 8 plans
Hawaii	7 of 8	3–4	$45.00	7 of 7 plans
Puerto Rico	3 of 3	3–4	—	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 — 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)$4.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.2338	$504.944 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$126.2338	$504.944 units	Quantity limit 4 per 28 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$132.9657	$531.864 units	Quantity limit 4 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.2407	$536.964 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.2338	$504.944 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$134.2407	$536.964 units	Quantity limit 4 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$132.9657	$531.864 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$119.9112	$479.644 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$119.9112	$479.644 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$122.9913	$491.974 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$122.9673	$491.874 units	Step therapy Quantity limit 4 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 — 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)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$125.9974	$503.994 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$125.9974	$503.994 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$133.6122	$534.454 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$133.6122	$534.454 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$125.9974	$503.994 units	Quantity limit 4 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$103.6617	$414.654 units	Quantity limit 4 per 30 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$103.6933	$414.774 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.4130	$481.654 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$120.4130	$481.654 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$123.1463	$492.594 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$123.1421	$492.574 units	Step therapy Quantity limit 4 per 30 days

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

North Carolina — 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)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.1844	$504.744 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.1844	$504.744 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$134.9856	$539.944 units	Quantity limit 4 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$134.2111	$536.844 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1844	$504.744 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$134.9856	$539.944 units	Quantity limit 4 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$134.2111	$536.844 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.7075	$486.834 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$121.7075	$486.834 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$124.4126	$497.654 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$124.4729	$497.894 units	Step therapy Quantity limit 4 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 — 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)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.1381	$504.554 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.1381	$504.554 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$135.3412	$541.364 units	Quantity limit 4 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$133.7144	$534.864 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1381	$504.554 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$135.3412	$541.364 units	Quantity limit 4 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	3Preferred Brand	$47.00	$94.00	$133.7144	$534.864 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.6140	$486.464 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$121.6140	$486.464 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$123.6828	$494.734 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$123.9015	$495.614 units	Step therapy Quantity limit 4 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 — 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)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.4452	$505.784 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.4452	$505.784 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.3172	$537.274 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$134.3172	$537.274 units	Quantity limit 4 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$126.6125	$506.454 units	Quantity limit 12 per 90 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.4452	$505.784 units	Quantity limit 4 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$126.6125	$506.454 units	Quantity limit 12 per 90 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$121.1157	$484.464 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.1157	$484.464 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.2019	$492.814 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$123.0320	$492.134 units	Step therapy Quantity limit 4 per 30 days

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

Illinois — 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)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$127.4284	$509.714 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$127.4284	$509.714 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$136.1218	$544.494 units	Quantity limit 4 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$133.9695	$535.884 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$136.1218	$544.494 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$127.4284	$509.714 units	Quantity limit 4 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$131.8763	$527.514 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$121.9226	$487.694 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.9226	$487.694 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.6050	$498.424 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$124.6537	$498.614 units	Step therapy Quantity limit 4 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 — 11 plans, 11 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	3Preferred Brand	20%	15%	$126.1648	$504.664 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.1648	$504.664 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$135.1664	$540.674 units	Quantity limit 4 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$134.0864	$536.354 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$135.1664	$540.674 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1648	$504.664 units	Quantity limit 4 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$131.7756	$527.104 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$121.2295	$484.924 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.2295	$484.924 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.8485	$495.394 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$123.8907	$495.564 units	Step therapy Quantity limit 4 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	3Preferred Brand	16%	16%	$133.7270	$534.914 units	Quantity limit 4 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$124.9987	$499.994 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$124.9987	$499.994 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$130.6077	$522.434 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$124.9987	$499.994 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$130.6077	$522.434 units	Quantity limit 4 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$133.6979	$534.794 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$140.0659	$560.264 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$140.0659	$560.264 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$141.3918	$565.574 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$141.3776	$565.514 units	Step therapy Quantity limit 4 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$134.5567	$538.234 units	Quantity limit 4 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$134.4427	$537.774 units	Quantity limit 4 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.5705	$506.284 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.5705	$506.284 units	Quantity limit 4 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$134.4427	$537.774 units	Quantity limit 4 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.5336	$538.134 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.5705	$506.284 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$134.5336	$538.134 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$126.7057	$506.824 units	Step therapy Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$125.2172	$500.874 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$125.2172	$500.874 units	Quantity limit 4 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 — 11 plans, 11 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	3Preferred Brand	18%	13%	$126.7207	$506.884 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.0245	$536.104 units	Quantity limit 4 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.7207	$506.884 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$134.0245	$536.104 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.7207	$506.884 units	Quantity limit 4 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$129.2933	$517.174 units	Quantity limit 4 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$129.2933	$517.174 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$124.3065	$497.234 units	Step therapy Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.7199	$482.884 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$120.7199	$482.884 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.3622	$497.454 units	Step therapy Quantity limit 4 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 — 10 plans, 9 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	3Preferred Brand	25%	20%	$126.6024	$506.414 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$126.6024	$506.414 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$134.7517	$539.014 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$134.7517	$539.014 units	Quantity limit 4 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$126.9380	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.6024	$506.414 units	Quantity limit 4 per 28 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.9913	$483.974 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$120.9913	$483.974 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.3524	$497.414 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$124.5345	$498.144 units	Step therapy Quantity limit 4 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 — 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)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.3707	$505.484 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.3134	$537.254 units	Quantity limit 4 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.3707	$505.484 units	Quantity limit 4 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$135.2547	$541.024 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.3707	$505.484 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$134.3134	$537.254 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$123.9014	$495.614 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$123.9014	$495.614 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$124.6299	$498.524 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.6792	$498.724 units	Step therapy Quantity limit 4 per 30 days

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

New Mexico — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.7115	$506.854 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$136.1250	$544.504 units	Quantity limit 4 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.7115	$506.854 units	Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.7115	$506.854 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$136.1250	$544.504 units	Quantity limit 4 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	3Preferred Brand	14%	14%	$132.2380	$528.954 units	Quantity limit 4 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$135.3712	$541.484 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$124.2163	$496.874 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$124.2163	$496.874 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$126.5511	$506.204 units	Step therapy Quantity limit 4 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$133.8455	$535.384 units	Quantity limit 4 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$125.7172	$502.874 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$125.7172	$502.874 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$133.8455	$535.384 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$125.7172	$502.874 units	Quantity limit 4 per 28 days
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$122.0799	$488.324 units	Step therapy Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$119.7600	$479.044 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$119.7600	$479.044 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$122.1428	$488.574 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.1997	$504.804 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.1997	$504.804 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.5030	$538.014 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$134.5030	$538.014 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1997	$504.804 units	Quantity limit 4 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.4538	$481.824 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$120.4538	$481.824 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.2153	$492.864 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$123.2185	$492.874 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.5059	$506.024 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.5059	$506.024 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$134.6733	$538.694 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.5059	$506.024 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$134.6733	$538.694 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$121.9478	$487.794 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.9478	$487.794 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.9399	$495.764 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$124.3788	$497.524 units	Step therapy Quantity limit 4 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 — 9 plans, 9 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	3Preferred Brand	20%	15%	$126.6987	$506.794 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.6987	$506.794 units	Quantity limit 4 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$134.9445	$539.784 units	Quantity limit 4 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$135.0977	$540.394 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.6987	$506.794 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$135.0977	$540.394 units	Quantity limit 4 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$134.9445	$539.784 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$120.9157	$483.664 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.9157	$483.664 units	Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.3684	$505.474 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.3684	$505.474 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$133.3048	$533.224 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.3684	$505.474 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$133.3048	$533.224 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$122.3334	$489.334 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$122.3334	$489.334 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.9560	$495.824 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$124.2593	$497.044 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.6043	$506.424 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.6043	$506.424 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.8681	$539.474 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.6043	$506.424 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$134.8681	$539.474 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$122.9252	$491.704 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$122.9252	$491.704 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.5027	$498.014 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.8099	$499.244 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.1181	$504.474 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.1181	$504.474 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$136.1716	$544.694 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1181	$504.474 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$136.1716	$544.694 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$121.8584	$487.434 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.8584	$487.434 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.9780	$495.914 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$123.9367	$495.754 units	Step therapy Quantity limit 4 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 — 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)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.4249	$505.704 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.4249	$505.704 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$135.6298	$542.524 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$135.6298	$542.524 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.4249	$505.704 units	Quantity limit 4 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.9601	$487.844 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$121.9601	$487.844 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.6871	$498.754 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.6908	$498.764 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$125.7325	$502.934 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$125.7325	$502.934 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$135.0334	$540.134 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$125.7325	$502.934 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$135.0334	$540.134 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$120.8495	$483.404 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.8495	$483.404 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$122.8739	$491.504 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$122.7208	$490.884 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$125.9519	$503.814 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$125.9519	$503.814 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$135.3908	$541.564 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$125.9519	$503.814 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$135.3908	$541.564 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$121.5435	$486.174 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.5435	$486.174 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.6191	$494.484 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.5212	$494.084 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.1728	$504.694 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.1728	$504.694 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$135.8417	$543.374 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1728	$504.694 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$135.8417	$543.374 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.5098	$482.044 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$120.5098	$482.044 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.2387	$492.954 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.2534	$493.014 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.8255	$507.304 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.8255	$507.304 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$135.3933	$541.574 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.8255	$507.304 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$135.3933	$541.574 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$124.3902	$497.564 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$124.3902	$497.564 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$125.4570	$501.834 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$124.9144	$499.664 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	23%	18%	$127.0807	$508.324 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$127.0807	$508.324 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$133.3881	$533.554 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$133.3881	$533.554 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$127.0807	$508.324 units	Quantity limit 4 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$123.9220	$495.694 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$123.9220	$495.694 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$126.4503	$505.804 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$126.2912	$505.164 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$127.0363	$508.154 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$127.0363	$508.154 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$135.5714	$542.294 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$135.5714	$542.294 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$127.0363	$508.154 units	Quantity limit 4 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$122.3194	$489.284 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$122.3194	$489.284 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$125.2403	$500.964 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$125.4259	$501.704 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.5147	$506.064 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.5147	$506.064 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.4830	$537.934 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.5147	$506.064 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$134.4830	$537.934 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$123.0715	$492.294 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$123.0715	$492.294 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.5115	$498.054 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.3543	$497.424 units	Step therapy Quantity limit 4 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 — 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	3Preferred Brand	25%	20%	$126.1856	$504.744 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.1856	$504.744 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.6564	$538.634 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.1856	$504.744 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$134.6564	$538.634 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$122.7971	$491.194 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$122.7971	$491.194 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$123.4478	$493.794 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$123.8381	$495.354 units	Step therapy Quantity limit 4 per 30 days

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

Maine and New Hampshire — 8 plans, 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	3Preferred Brand	25%	20%	$126.3603	$505.444 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$126.3603	$505.444 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$135.2985	$541.194 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$135.2985	$541.194 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.3603	$505.444 units	Quantity limit 4 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$122.2576	$489.034 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$122.2576	$489.034 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$124.6958	$498.784 units	Step therapy Quantity limit 4 per 30 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 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)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$126.9597	$507.844 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$134.2770	$537.114 units	Quantity limit 4 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$126.9597	$507.844 units	Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$126.9597	$507.844 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$134.2770	$537.114 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$120.8206	$483.284 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$120.8206	$483.284 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$125.0760	$500.304 units	Step therapy Quantity limit 4 per 30 days

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

Virginia — 8 plans, 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	3Preferred Brand	25%	20%	$127.0720	$508.294 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$127.0720	$508.294 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$135.2256	$540.904 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$127.0720	$508.294 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$135.2256	$540.904 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$121.9601	$487.844 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.9601	$487.844 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$125.4789	$501.924 units	Step therapy Quantity limit 4 per 30 days

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

Alaska — 8 plans, 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	3Preferred Brand	24%	19%	$127.3044	$509.224 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$127.3044	$509.224 units	Quantity limit 4 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$130.3563	$521.434 units	Quantity limit 4 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$130.3563	$521.434 units	Quantity limit 4 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$127.3044	$509.224 units	Quantity limit 4 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$139.5419	$558.174 units	Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$139.8915	$559.574 units	Step therapy Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$139.5419	$558.174 units	Quantity limit 4 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$133.6760	$534.704 units	Quantity limit 4 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$127.8382	$511.354 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$127.8382	$511.354 units	Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$127.8382	$511.354 units	Quantity limit 4 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$133.6760	$534.704 units	Quantity limit 4 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$121.2959	$485.184 units	Quantity limit 4 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$121.2959	$485.184 units	Quantity limit 4 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
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$133.2054	$532.824 units	Quantity limit 4 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$120.4775	$481.914 units	Step therapy Quantity limit 4 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$120.4291	$481.724 units	Step therapy Quantity limit 4 per 30 days

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$137.6973	$550.794 units	Quantity limit 4 per 30 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$133.2645	$533.064 units	Quantity limit 4 per 30 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$132.1118	$528.454 units	Quantity limit 4 per 30 days

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

U.S. Virgin Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$148.8196	$595.284 units	Quantity limit 4 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.

SPIRIVA RESPIMAT 3.124 ug Spray, Metered

Coverage by region

Plan-by-plan detail