BESIVANCE 6 mg/mL Suspension
Also known as Besifloxacin. Package: 1 BOTTLE, DROPPER in 1 CARTON (24208-446-05) / 5 mL in 1 BOTTLE, DROPPER. NDC 24208044605.
- Plans covering it
- 126
- across 39 regions checked
- Lowest tier
- 3
- lower tiers cost less
- Plans with restrictions
- 0
- prior auth, step therapy or quantity limit
Coverage by region
Covered by at least one plan in 39 of 39 CMS regions.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| Pennsylvania and West Virginia | 6 of 12 | 3–4 | — | none |
| Connecticut, Massachusetts, Rhode Island and Vermont | 5 of 11 | 3–4 | $30.00 | none |
| Arkansas | 5 of 12 | 3–4 | — | none |
| California | 5 of 12 | 3–4 | — | none |
| New Jersey | 4 of 12 | 3–4 | — | none |
| North Carolina | 4 of 12 | 3–4 | $45.00 | none |
| South Carolina | 4 of 11 | 4 | — | none |
| Alabama and Tennessee | 4 of 12 | 3–4 | $47.00 | none |
| Indiana and Kentucky | 4 of 10 | 3–4 | — | none |
| Wisconsin | 4 of 10 | 3–4 | — | none |
| Illinois | 4 of 12 | 3–4 | — | none |
| Louisiana | 4 of 10 | 3–4 | — | none |
| Texas | 4 of 12 | 3–4 | — | none |
| Oklahoma | 4 of 11 | 3–4 | — | none |
| Kansas | 4 of 12 | 3–4 | — | none |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 4 of 11 | 3–4 | — | none |
| Idaho and Utah | 4 of 10 | 3–4 | — | none |
| New York | 3 of 10 | 4 | — | none |
| Delaware, DC and Maryland | 3 of 10 | 4 | — | none |
| Georgia | 3 of 10 | 4 | — | none |
| Michigan | 3 of 12 | 4 | — | none |
| Ohio | 3 of 10 | 4 | — | none |
| Missouri | 3 of 10 | 4 | — | none |
| Mississippi | 3 of 10 | 4 | — | none |
| New Mexico | 3 of 11 | 3–4 | — | none |
| Colorado | 3 of 10 | 4 | — | none |
| Arizona | 3 of 10 | 4 | — | none |
| Nevada | 3 of 10 | 4 | — | none |
| Oregon and Washington | 3 of 10 | 4 | — | none |
| Puerto Rico | 3 of 3 | 4 | — | none |
| Maine and New Hampshire | 2 of 9 | 4 | — | none |
| Virginia | 2 of 9 | 4 | — | none |
| Florida | 2 of 10 | 3–4 | — | none |
| Hawaii | 2 of 8 | 3–4 | — | none |
| Alaska | 2 of 9 | 4 | — | none |
| American Samoa | 1 of 1 | 4 | — | none |
| Guam | 1 of 1 | 4 | — | none |
| Northern Mariana Islands | 1 of 1 | 4 | — | none |
| U.S. Virgin Islands | 1 of 1 | 4 | — | none |
Plan-by-plan detail
Open a region to see every plan that covers this drug, with tier, cost-sharing and restrictions.
Pennsylvania and West Virginia — 6 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2722 | — | None |
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.0947 | — | None |
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.0956 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 33% | — | $46.4403 | — | None |
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 4Non-Preferred Drug | 25% | 25% | $43.2424 | — | None |
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 25% | 25% | $43.1046 | — | 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 — 5 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $43.9215 | — | None |
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2722 | — | None |
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 3Preferred Brand | $30.00 | $60.00 | $43.9215 | — | None |
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.0719 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible | 4Non-Preferred Drug | 30% | — | $46.5139 | — | 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 — 5 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $44.6649 | — | None |
| BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible | 3Preferred Brand | 20% | 20% | $44.6649 | — | None |
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $42.7292 | — | None |
| HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $42.7319 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 29% | — | $47.3505 | — | 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 — 5 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $44.9719 | — | None |
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 3Preferred Brand | 19% | 19% | $44.9719 | — | None |
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $42.9300 | — | None |
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.9354 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible | 4Non-Preferred Drug | 31% | — | $46.4271 | — | 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 Jersey — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 3Preferred Brand | 20% | 20% | $46.2361 | — | None |
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.8711 | — | None |
| HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 27% | 27% | $42.8638 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 33% | — | $46.6211 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $135.00 | $46.8938 | — | None |
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $42.6488 | — | None |
| HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $42.6610 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible | 4Non-Preferred Drug | 33% | — | $46.8751 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.0433 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $46.4937 | — | None |
| BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 50% | 50% | $44.3379 | — | None |
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $42.0893 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible | 3Preferred Brand | $47.00 | $94.00 | $47.3787 | — | None |
| HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.3765 | — | None |
| HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $43.4963 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $47.2249 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2722 | — | None |
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.3955 | — | None |
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.4490 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $47.1987 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2722 | — | None |
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.1233 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $43.1275 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $46.3306 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $45.6517 | — | None |
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.9022 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 38% | — | $47.2437 | — | None |
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $42.9139 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2722 | — | None |
| HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.1117 | — | None |
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.1076 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $46.9792 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $45.9661 | — | None |
| HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.9275 | — | None |
| HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $42.9139 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $46.6863 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $45.8325 | — | None |
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.7263 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible | 4Non-Preferred Drug | 40% | — | $46.9796 | — | None |
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $42.7199 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $46.6093 | — | None |
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 3Preferred Brand | 20% | 20% | $46.5080 | — | None |
| HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.1098 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible | 4Non-Preferred Drug | 38% | — | $46.6133 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2722 | — | None |
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $42.8559 | — | None |
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.8479 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $46.7976 | — | 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 — 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.3168 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.2590 | — | None |
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.3874 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $47.2907 | — | 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 — 3 plans
| 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 | 4Non-Preferred Drug | 29% | 29% | $41.8066 | — | None |
| HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $41.8109 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible | 4Non-Preferred Drug | 28% | — | $46.3051 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.6433 | — | None |
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $43.6218 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $46.4800 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.1681 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $46.9098 | — | None |
| HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.3578 | — | 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 — 3 plans
| 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 | 4Non-Preferred Drug | 30% | 30% | $43.0227 | — | None |
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $42.9920 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible | 4Non-Preferred Drug | 32% | — | $47.0581 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $42.2707 | — | None |
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $42.3253 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $46.5613 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.6021 | — | None |
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.5897 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $47.2574 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.3036 | — | None |
| HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.1479 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $46.9818 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible | 3Preferred Brand | 14% | 14% | $45.8603 | — | None |
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $42.4060 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $46.7079 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $41.9544 | — | None |
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $41.8881 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 37% | — | $46.6014 | — | 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 — 3 plans
| 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 | 4Non-Preferred Drug | 29% | 29% | $43.7240 | — | None |
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $43.6787 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $47.6331 | — | 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 — 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.5603 | — | None |
| HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.6306 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $47.3428 | — | 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 — 3 plans
| 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 | 4Non-Preferred Drug | 30% | 30% | $43.2593 | — | None |
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $43.1870 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible | 4Non-Preferred Drug | 37% | — | $46.8662 | — | 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
| 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 | 4Non-Preferred Drug | 31% | 31% | $43.8528 | — | None |
| HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 34% | 34% | $43.8587 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 25% | 25% | $46.1282 | — | 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 — 2 plans
| 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 | 4Non-Preferred Drug | 30% | 30% | $42.8800 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible | 4Non-Preferred Drug | 30% | — | $46.1006 | — | 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 — 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $46.6386 | — | None |
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $42.8224 | — | 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 — 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $47.4893 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $46.8534 | — | 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 — 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $45.2923 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $46.5186 | — | 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 — 2 plans
| 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 | 4Non-Preferred Drug | 29% | 29% | $40.7000 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $46.9287 | — | 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.
American Samoa — 1 plan
| 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 | 4Non-Preferred Drug | 25% | 25% | $48.0496 | — | 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.
Guam — 1 plan
| 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 | 4Non-Preferred Drug | 25% | 25% | $48.0496 | — | 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.
Northern Mariana Islands — 1 plan
| 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 | 4Non-Preferred Drug | 25% | 25% | $48.0496 | — | 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.
U.S. Virgin Islands — 1 plan
| 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 | 4Non-Preferred Drug | 25% | 25% | $48.0496 | — | 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.