NYAMYC 100000 [USP'U]/g Powder (Nystatin) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	2–4	$8.00	7 of 12 plans
Pennsylvania and West Virginia	12 of 12	2–4	$5.00	9 of 12 plans
North Carolina	12 of 12	2–4	$8.00	7 of 12 plans
Alabama and Tennessee	12 of 12	2–4	$8.00	7 of 12 plans
Michigan	12 of 12	2–4	$8.00	9 of 12 plans
Illinois	12 of 12	2–4	$8.00	7 of 12 plans
Arkansas	12 of 12	2–4	$7.00	9 of 12 plans
Texas	12 of 12	2–4	$7.00	7 of 12 plans
Kansas	12 of 12	2–4	$7.00	6 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	2–4	$8.00	8 of 11 plans
South Carolina	11 of 11	2–4	$7.00	8 of 11 plans
Oklahoma	11 of 11	2–4	$7.00	6 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	2–4	$7.00	7 of 11 plans
New Mexico	11 of 11	2–4	$6.00	6 of 11 plans
New York	10 of 10	2–4	$8.00	7 of 10 plans
Delaware, DC and Maryland	10 of 10	2–4	$8.00	7 of 10 plans
Georgia	10 of 10	2–4	$8.00	7 of 10 plans
Florida	10 of 10	2–4	$8.00	5 of 10 plans
Ohio	10 of 10	2–4	$8.00	7 of 10 plans
Indiana and Kentucky	10 of 10	2–4	$7.00	7 of 10 plans
Wisconsin	10 of 10	2–4	$7.00	7 of 10 plans
Missouri	10 of 10	2–4	$8.00	7 of 10 plans
Mississippi	10 of 10	2–4	$6.00	7 of 10 plans
Louisiana	10 of 10	2–4	$6.00	7 of 10 plans
Colorado	10 of 10	2–4	$8.00	7 of 10 plans
Arizona	10 of 10	2–4	$8.00	7 of 10 plans
Nevada	10 of 10	2–4	$6.00	7 of 10 plans
Oregon and Washington	10 of 10	2–4	$8.00	7 of 10 plans
Idaho and Utah	10 of 10	2–4	$8.00	7 of 10 plans
California	10 of 12	2–4	$7.00	7 of 10 plans
Maine and New Hampshire	9 of 9	2–4	$7.00	6 of 9 plans
Virginia	9 of 9	2–4	$8.00	6 of 9 plans
Alaska	9 of 9	2–4	$8.00	6 of 9 plans
Hawaii	8 of 8	2–4	$8.00	5 of 8 plans
Puerto Rico	3 of 3	2–3	—	3 of 3 plans
American Samoa	1 of 1	2	—	1 of 1 plans
Guam	1 of 1	2	—	1 of 1 plans
Northern Mariana Islands	1 of 1	2	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	2	—	1 of 1 plans

New Jersey — 12 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)$77.40/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3420	$4.1012 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4196	$5.0412 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.2570	$4.6318 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2610	$1.576 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2546	$4.5818 units	Quantity limit 18 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$0.7306	—	None
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3685	—	None
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2779	$3.3312 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5285	$6.3412 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3686	—	None
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$0.7306	—	None
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3685	—	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.

Pennsylvania and West Virginia — 12 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)$43.50/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3219	$3.8612 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4212	$5.0512 units	Quantity limit 12 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.3022	$1.816 units	Quantity limit 6 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.3022	$1.816 units	Quantity limit 6 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1736	$1.046 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3765	$6.7818 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.3207	$5.7718 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3683	—	None
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.1897	$2.2812 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.6622	$7.9512 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3685	—	None
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3681	—	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 — 12 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)$56.90/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3527	$4.2312 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4207	$5.0512 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2823	$5.0818 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2739	$1.646 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.2692	$4.8518 units	Quantity limit 18 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$0.9327	—	None
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2479	$2.9712 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4952	$5.9412 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3694	—	None
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3697	—	None
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.9327	—	None
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3692	—	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.

Alabama and Tennessee — 12 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)$63.20/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3535	$4.2412 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4188	$5.0312 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2765	$4.9818 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.2649	$4.7718 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3916	$2.356 units	Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3705	—	None
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2581	$3.1012 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4657	$5.5912 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3707	—	None
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$0.7539	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3704	—	None
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$0.7539	—	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.

Michigan — 12 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)$14.10/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3340	$4.0112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4218	$5.0612 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2665	$4.8018 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2934	$5.2818 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3029	$1.826 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4223	$5.0712 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2868	$3.4412 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3759	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3760	—	None
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.2890	$1.736 units	Quantity limit 18 per 90 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3758	—	None
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	4Non-Preferred Drug	27%	27%	$0.2890	$1.736 units	Quantity limit 18 per 90 days

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

Illinois — 12 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)$40.20/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3059	$3.6712 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4116	$4.9412 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3313	$5.9618 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2306	$1.386 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2838	$5.1118 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.8000	—	None
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5405	$6.4912 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2240	$2.6912 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3745	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3748	—	None
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$0.8364	—	None
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3744	—	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.

Arkansas — 12 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)$65.10/mo premium · $615.00 deductible	2Generic	$7.00	$27.00	$0.3594	$4.3112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	2Generic	$10.00	$54.00	$0.4232	$5.0812 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2498	$4.5018 units	Quantity limit 18 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.6746	$4.056 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2491	$4.4818 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2585	$1.556 units	Quantity limit 6 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.6746	$4.056 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3734	$4.4812 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3062	$3.6712 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3652	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3654	—	None
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3651	—	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.

Texas — 12 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)$89.20/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3641	$4.3712 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4257	$5.1112 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2978	$5.3618 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2134	$1.286 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2768	$4.9818 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.8584	—	None
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4616	$5.5412 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2620	$3.1412 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3697	—	None
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3690	—	None
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$0.8222	—	None
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3687	—	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.

Kansas — 12 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3088	$3.7112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4151	$4.9812 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2357	$4.2418 units	Quantity limit 18 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.9613	—	None
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3536	$2.126 units	Quantity limit 6 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.9541	—	None
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.9613	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2222	$2.6712 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.6686	$8.0212 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3642	—	None
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3643	—	None
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3642	—	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.

Connecticut, Massachusetts, Rhode Island and Vermont — 11 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.4163	$5.0012 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4856	$5.8312 units	Quantity limit 12 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4110	$2.476 units	Quantity limit 6 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2074	$1.246 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2744	$4.9418 units	Quantity limit 18 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$0.4110	$2.476 units	Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3717	—	None
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2141	$2.5712 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6287	$7.5412 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.3718	—	None
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3717	—	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.

South Carolina — 11 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3348	$4.0212 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4274	$5.1312 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3257	$5.8618 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2568	$1.546 units	Quantity limit 6 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3398	$4.0812 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2902	$5.2218 units	Quantity limit 18 per 30 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2047	$2.4612 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6030	$7.2412 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.3749	—	None
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3754	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3746	—	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.

Oklahoma — 11 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3604	$4.3212 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4252	$5.1012 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2551	$4.5918 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2565	$4.6218 units	Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.0015	—	None
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.9453	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$0.3648	—	None
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3081	$3.7012 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4300	$5.1612 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3652	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3646	—	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.

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 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)$5.30/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3282	$3.9412 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3854	$4.6212 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2125	$1.276 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2081	$3.7518 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2119	$3.8118 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3645	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.1975	$2.3712 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.8117	$9.7412 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3646	—	None
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$0.6935	—	None
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3644	—	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 Mexico — 11 plans, 6 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	2Generic	$6.00	$18.00	$0.2950	$3.5412 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4225	$5.0712 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.3229	$5.8118 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3703	$2.226 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4862	$5.8312 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2686	$3.2212 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3828	—	None
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.3830	—	None
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3828	—	None
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.8976	—	None
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.9127	—	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 — 10 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)$105.80/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3488	$4.1912 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4258	$5.1112 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2677	$4.8218 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2693	$4.8518 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3497	$2.106 units	Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2904	$3.4812 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4347	$5.2212 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.3660	—	None
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.3661	—	None
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3660	—	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.

Delaware, DC and Maryland — 10 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)$37.80/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3281	$3.9412 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4015	$4.8212 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.2557	$4.6018 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2695	$4.8518 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.5244	$3.156 units	Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3697	—	None
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3698	—	None
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.1792	$2.1512 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.7125	$8.5512 units	Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3696	—	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.

Georgia — 10 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)$98.00/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3455	$4.1512 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4190	$5.0312 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2906	$5.2318 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3390	$2.036 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2829	$5.0918 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5525	$6.6312 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2280	$2.7412 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3721	—	None
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3725	—	None
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3719	—	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.

Florida — 10 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3480	$4.1812 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4181	$5.0212 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2309	$1.396 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4067	$4.8812 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2683	$3.2212 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3832	—	None
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.3830	—	None
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.8621	—	None
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3828	—	None
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.8621	—	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.

Ohio — 10 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)$73.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3522	$4.2312 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4178	$5.0112 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5134	$9.2418 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3409	$2.056 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.3870	$6.9718 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.3782	—	None
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.1967	$2.3612 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.7378	$8.8512 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3784	—	None
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3780	—	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.

Indiana and Kentucky — 10 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)$90.30/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3431	$4.1212 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4164	$5.0012 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1919	$1.156 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2827	$5.0918 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2764	$4.9818 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3734	—	None
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2684	$3.2212 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4049	$4.8612 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3737	—	None
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3733	—	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.

Wisconsin — 10 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	2Generic	$7.00	$21.00	$0.3505	$4.2112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4125	$4.9512 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2635	$4.7418 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.3305	$1.986 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2745	$4.9418 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4215	$5.0612 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2921	$3.5112 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3703	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3705	—	None
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3702	—	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.

Missouri — 10 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)$71.90/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3344	$4.0112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4400	$5.2812 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2397	$4.3118 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2388	$4.3018 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3007	$1.806 units	Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2408	$2.8912 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.5509	$6.6112 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3667	—	None
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3670	—	None
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3665	—	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.

Mississippi — 10 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)$84.70/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.3399	$4.0812 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4341	$5.2112 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2522	$4.5418 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2563	$4.6118 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2321	$1.396 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.3392	$4.0712 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3044	$3.6512 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3665	—	None
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3667	—	None
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3663	—	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.

Louisiana — 10 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)$37.00/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.3558	$4.2712 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4214	$5.0612 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1860	$1.126 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2646	$4.7618 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2667	$4.8018 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3670	—	None
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3038	$3.6512 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3504	$4.2012 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.3673	—	None
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3668	—	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.

Colorado — 10 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)$125.00/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3497	$4.2012 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4114	$4.9412 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2913	$5.2418 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2794	$5.0318 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3542	$2.136 units	Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3060	$3.6712 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.3665	—	None
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4151	$4.9812 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3669	—	None
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3663	—	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.

Arizona — 10 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)$38.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3566	$4.2812 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4282	$5.1412 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4004	$7.2118 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4583	$8.2518 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4377	$2.636 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.4999	$6.0012 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2829	$3.3912 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.3818	—	None
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3823	—	None
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3815	—	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.

Nevada — 10 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)$76.70/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.3182	$3.8212 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3977	$4.7712 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3753	$6.7618 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.3262	$5.8718 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3610	$2.176 units	Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3888	—	None
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5886	$7.0612 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2430	$2.9212 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.3893	—	None
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3886	—	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.

Oregon and Washington — 10 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)$38.40/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3065	$3.6812 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4495	$5.3912 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$0.3339	$6.0118 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.3524	$6.3418 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2835	$1.706 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5211	$6.2512 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2267	$2.7212 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3811	—	None
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3813	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3809	—	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.

Idaho and Utah — 10 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)$56.50/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3591	$4.3112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4242	$5.0912 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2079	$1.256 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2564	$4.6218 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.2601	$4.6818 units	Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3652	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3047	$3.6612 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3653	—	None
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3554	$4.2612 units	Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3651	—	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.

California — 10 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)$109.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3413	$4.1012 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4280	$5.1412 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2690	$4.8418 units	Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2821	$5.0818 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2823	$1.696 units	Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2897	$3.4812 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4190	$5.0312 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3688	—	None
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3685	—	None
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3684	—	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.

Maine and New Hampshire — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.3209	$3.8512 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3801	$4.5612 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2594	$4.6718 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.9041	$5.426 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.7835	$9.4012 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.1658	$1.9912 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3667	—	None
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.3668	—	None
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3666	—	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.

Virginia — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3281	$3.9412 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4069	$4.8812 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.6000	$3.606 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.3478	$6.2618 units	Quantity limit 18 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6542	$7.8512 units	Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3342	$4.0112 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3698	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.3703	—	None
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3695	—	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.

Alaska — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.3517	$4.2212 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.4113	$4.9412 units	Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.2872	$5.1718 units	Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.6119	$3.676 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3621	$4.3512 units	Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.3643	—	None
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.3647	—	None
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2882	$3.4612 units	Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.3641	—	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.

Hawaii — 8 plans, 5 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	2Generic	$8.00	$24.00	$0.3260	$3.9112 units	Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3866	$4.6412 units	Quantity limit 12 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2255	$1.356 units	Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.4180	—	None
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3145	$3.7712 units	Quantity limit 12 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.4471	$5.3712 units	Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.4233	—	None
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.4151	—	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.

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	2Generic	25%	25%	$0.3734	$4.4812 units	Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0491	$18.8818 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5304	$9.5518 units	Quantity limit 18 per 30 days

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

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	2Generic	25%	25%	$0.4382	$5.2612 units	Quantity limit 12 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	2Generic	25%	25%	$0.4382	$5.2612 units	Quantity limit 12 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	2Generic	25%	25%	$0.4382	$5.2612 units	Quantity limit 12 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	2Generic	25%	25%	$0.4197	$5.0412 units	Quantity limit 12 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.

NYAMYC 100000 [USP'U]/g Powder

Coverage by region

Plan-by-plan detail