QUETIAPINE FUMARATE 150 mg Tablet, Film Coated

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	2–4	$0.00	10 of 12 plans
Pennsylvania and West Virginia	12 of 12	2–4	$0.00	10 of 12 plans
North Carolina	12 of 12	2–4	$0.00	10 of 12 plans
Alabama and Tennessee	12 of 12	2–4	$0.00	10 of 12 plans
Michigan	12 of 12	2–4	$0.00	10 of 12 plans
Illinois	12 of 12	2–4	$0.00	10 of 12 plans
Arkansas	12 of 12	2–4	$0.00	10 of 12 plans
Texas	12 of 12	2–4	$0.00	10 of 12 plans
Kansas	12 of 12	2–4	$0.00	10 of 12 plans
California	12 of 12	2–4	$0.00	8 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	2–4	$0.00	9 of 11 plans
South Carolina	11 of 11	2–4	$0.00	9 of 11 plans
Oklahoma	11 of 11	2–4	$0.00	9 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	2–4	$0.00	9 of 11 plans
New Mexico	11 of 11	2–4	$0.00	9 of 11 plans
New York	10 of 10	2–4	$0.00	8 of 10 plans
Delaware, DC and Maryland	10 of 10	2–4	$0.00	8 of 10 plans
Georgia	10 of 10	2–4	$0.00	8 of 10 plans
Florida	10 of 10	2–4	$0.00	8 of 10 plans
Ohio	10 of 10	2–4	$0.00	8 of 10 plans
Indiana and Kentucky	10 of 10	2–4	$0.00	8 of 10 plans
Wisconsin	10 of 10	2–4	$0.00	8 of 10 plans
Missouri	10 of 10	2–4	$0.00	8 of 10 plans
Mississippi	10 of 10	2–4	$0.00	8 of 10 plans
Louisiana	10 of 10	2–4	$0.00	8 of 10 plans
Colorado	10 of 10	2–4	$0.00	8 of 10 plans
Arizona	10 of 10	2–4	$0.00	8 of 10 plans
Nevada	10 of 10	2–4	$0.00	8 of 10 plans
Oregon and Washington	10 of 10	2–4	$0.00	8 of 10 plans
Idaho and Utah	10 of 10	2–4	$0.00	8 of 10 plans
Maine and New Hampshire	9 of 9	2–4	$0.00	7 of 9 plans
Virginia	9 of 9	2–4	$0.00	7 of 9 plans
Alaska	9 of 9	2–4	$0.00	7 of 9 plans
Hawaii	8 of 8	2–4	$0.00	6 of 8 plans
Puerto Rico	3 of 3	2	$2.00	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, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4402	$4.323 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4402	$4.323 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.3958	$12.569 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.3959	$12.569 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4402	$4.323 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.8032	$7.239 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3553	—	None
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2650	$11.389 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3553	—	None
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$1.5486	$23.2315 units	Prior authorization Quantity limit 15 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$1.5486	$23.2315 units	Prior authorization Quantity limit 15 per 30 days

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

Pennsylvania and West Virginia — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4491	$4.353 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4491	$4.353 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3351	$12.029 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4001	$12.609 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4005	$12.609 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.8384	$7.559 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4491	$4.353 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3587	—	None
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$1.2349	$11.119 units	Quantity limit 9 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$1.4046	$84.2860 units	Quantity limit 62 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.4042	$84.2560 units	Quantity limit 62 per 31 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3587	—	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, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5072	$4.523 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5072	$4.523 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4205	$12.789 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4218	$12.809 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5072	$4.523 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6507	$5.869 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3754	—	None
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2249	$11.029 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3349	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3754	—	None
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.5449	$23.1715 units	Prior authorization Quantity limit 15 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$1.5449	$23.1715 units	Prior authorization Quantity limit 15 per 30 days

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

Alabama and Tennessee — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5238	$4.573 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5238	$4.573 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4187	$12.779 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4210	$12.799 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5238	$4.573 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6328	$5.709 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3800	—	None
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2196	$10.989 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3800	—	None
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$1.5340	$23.0115 units	Prior authorization Quantity limit 15 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$1.5340	$23.0115 units	Prior authorization Quantity limit 15 per 30 days

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

Michigan — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4027	$12.629 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4566	$4.373 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4566	$4.373 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4006	$12.619 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7786	$7.019 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4566	$4.373 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3684	—	None
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2290	$11.069 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$1.2324	$18.4915 units	Quantity limit 45 per 90 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$1.2324	$18.4915 units	Quantity limit 45 per 90 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3684	—	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.

Illinois — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4946	$4.483 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4946	$4.483 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4142	$12.739 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6948	$6.259 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4162	$12.759 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4946	$4.483 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3774	—	None
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2220	$11.009 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3774	—	None
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$1.5550	$23.3215 units	Prior authorization Quantity limit 15 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.5361	$23.0415 units	Prior authorization Quantity limit 15 per 30 days

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

Arkansas — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4035	$12.639 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5227	$4.573 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5227	$4.573 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4020	$12.629 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5227	$4.573 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	2Generic	$10.00	$54.00	$0.7330	$6.609 units	Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	2Generic	$5.00	$15.00	$0.8088	$7.289 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3726	—	None
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.8088	$7.289 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2163	$10.959 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3316	$11.989 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3726	—	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, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4872	$4.463 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4872	$4.463 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4038	$12.639 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4053	$12.659 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7137	$6.429 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4872	$4.463 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3718	—	None
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2047	$10.849 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3718	—	None
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$1.5383	$23.0715 units	Prior authorization Quantity limit 15 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.5127	$22.6915 units	Prior authorization Quantity limit 15 per 30 days

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

Kansas — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4335	$12.909 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5364	$4.613 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5364	$4.613 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5364	$4.613 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7524	$6.779 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.4202	—	None
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2195	$10.989 units	Quantity limit 9 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.5597	$23.4015 units	Prior authorization Quantity limit 15 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.5595	$23.3915 units	Prior authorization Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.4202	—	None
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$1.5595	$23.3915 units	Prior authorization Quantity limit 15 per 30 days

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

California — 12 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4178	$12.769 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4179	$12.769 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4664	$4.403 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4664	$4.403 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7405	$6.669 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4664	$4.403 units	Quantity limit 3 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	2Generic	$7.00	$17.50	$1.3391	—	None
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$1.3391	—	None
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3672	—	None
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2329	$11.109 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3672	—	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, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4512	$4.353 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4512	$4.353 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4512	$4.353 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4217	$12.809 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7908	$7.129 units	Quantity limit 9 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.8009	$7.219 units	Quantity limit 9 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.8009	$7.219 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3673	—	None
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2379	$11.149 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3673	—	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, 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	2Generic	$2.00	$0.00	$1.4916	$4.473 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4916	$4.473 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4210	$12.799 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7161	$6.449 units	Quantity limit 9 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	2Generic	$17.00	$42.50	$1.1962	$10.779 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4916	$4.473 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4236	$12.819 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3713	—	None
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2322	$11.099 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3713	—	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, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$2.00	$0.00	$1.5635	$4.693 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5635	$4.693 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4257	$12.839 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5635	$4.693 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.5836	$5.259 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4257	$12.839 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3832	—	None
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2140	$10.939 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.5134	$22.7015 units	Prior authorization Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3832	—	None
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.5201	$22.8015 units	Prior authorization Quantity limit 15 per 30 days

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5113	$4.533 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5113	$4.533 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3343	$12.019 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4010	$12.619 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5113	$4.533 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4033	$12.639 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.8952	$8.069 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2234	$11.019 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3963	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3963	—	None
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$1.5527	$23.2915 units	Prior authorization Quantity limit 15 per 30 days

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

New Mexico — 11 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4275	$12.859 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5155	$4.553 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5155	$4.553 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5155	$4.553 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6290	$5.669 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3933	—	None
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$1.2168	$10.959 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3343	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3933	—	None
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5179	$22.7715 units	Prior authorization Quantity limit 15 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.5507	$23.2615 units	Prior authorization Quantity limit 15 per 30 days

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

New York — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	2Generic	10%	10%	$1.3889	$12.509 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.3894	$12.509 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4125	$4.243 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4125	$4.243 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.9384	$8.459 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4125	$4.243 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3605	—	None
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2456	$11.219 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3355	$12.029 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3605	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4333	$4.303 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4333	$4.303 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.3908	$12.529 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.3905	$12.519 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.8396	$7.569 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4333	$4.303 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3537	—	None
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2436	$11.199 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3537	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5109	$4.533 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5109	$4.533 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4220	$12.809 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5109	$4.533 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6933	$6.249 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4271	$12.849 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3865	—	None
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2182	$10.969 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3342	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3865	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4650	$4.403 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4650	$4.403 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4650	$4.403 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7578	$6.829 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3672	—	None
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2365	$11.139 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3672	—	None
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.5538	$23.3115 units	Prior authorization Quantity limit 15 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$1.5538	$23.3115 units	Prior authorization Quantity limit 15 per 30 days

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

Ohio — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4995	$4.503 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4995	$4.503 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4166	$12.759 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4203	$12.789 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4995	$4.503 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.9580	$8.629 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3888	—	None
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2298	$11.079 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3375	$12.049 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3888	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4906	$4.473 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4906	$4.473 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3347	$12.019 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4145	$12.739 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4173	$12.769 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4906	$4.473 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6817	$6.149 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3887	—	None
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.1957	$10.769 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3887	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4192	$12.779 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5235	$4.573 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5235	$4.573 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3348	$12.019 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4176	$12.769 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5235	$4.573 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.5825	$5.249 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3883	—	None
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2186	$10.979 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3883	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5312	$4.593 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5312	$4.593 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4126	$12.719 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4129	$12.729 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7425	$6.689 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5312	$4.593 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3776	—	None
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2233	$11.019 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3342	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3776	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5274	$4.583 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5274	$4.583 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4054	$12.659 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4051	$12.659 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5274	$4.583 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6581	$5.929 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3737	—	None
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2166	$10.959 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3737	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5255	$4.583 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5255	$4.583 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3348	$12.019 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4080	$12.679 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4077	$12.679 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5255	$4.583 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7205	$6.489 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3708	—	None
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$1.2170	$10.959 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3708	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5358	$4.613 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5358	$4.613 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4273	$12.859 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4215	$12.799 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5358	$4.613 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6642	$5.989 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.4161	—	None
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$1.1879	$10.699 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.4161	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4325	$12.899 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$3.00	$0.00	$1.4827	$4.453 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4827	$4.453 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4317	$12.899 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.9657	$8.699 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4827	$4.453 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.4032	—	None
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.2258	$11.039 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3340	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.4032	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4983	$4.493 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4983	$4.493 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4230	$12.819 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4241	$12.829 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.5589	$5.039 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4983	$4.493 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3805	—	None
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$1.2280	$11.059 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3805	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4194	$12.779 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4620	$4.393 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4620	$4.393 units	Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.4189	$12.779 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4620	$4.393 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.8242	$7.429 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.4016	—	None
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.1976	$10.789 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.4016	—	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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.4804	$4.443 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4804	$4.443 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3348	$12.019 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.3968	$12.579 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4804	$4.443 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.3994	$12.599 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7878	$7.099 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3798	—	None
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2118	$10.919 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3798	—	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, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4317	$12.899 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5059	$4.523 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5059	$4.523 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7347	$6.619 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5059	$4.523 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3947	—	None
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2184	$10.979 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3316	$11.989 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3947	—	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, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$1.5183	$4.553 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5183	$4.553 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5183	$4.553 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.6792	$6.119 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.4275	$12.859 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3821	—	None
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2202	$10.989 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3348	$12.019 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3821	—	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, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$1.4070	$12.669 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$3.00	$0.00	$1.5141	$4.543 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.5141	$4.543 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.8120	$7.319 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.5141	$4.543 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.4088	—	None
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$1.1888	$10.709 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.3606	$12.259 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.4088	—	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, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	2Generic	$4.00	$0.00	$1.4837	$4.453 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$1.3337	$12.009 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$1.4837	$4.453 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$1.4837	$4.453 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.7245	$6.529 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$1.2299	$11.079 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1.3699	—	None
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.3699	—	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
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$1.3671	$12.309 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$1.3671	$12.309 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	2Generic	25%	25%	$0.8562	$7.719 units	Quantity limit 9 per 30 days

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	25%	25%	$1.1112	$10.009 units	Quantity limit 9 per 30 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	25%	25%	$1.1112	$10.009 units	Quantity limit 9 per 30 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	2Generic	25%	25%	$1.1112	$10.009 units	Quantity limit 9 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	2Generic	25%	25%	$1.1112	$10.009 units	Quantity limit 9 per 30 days

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

Coverage by region

Plan-by-plan detail