CLINDAMYCIN PHOSPHATE 10 mg/mL Solution

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Pennsylvania and West Virginia	8 of 12	2–4	$0.00	3 of 8 plans
Michigan	8 of 12	2–4	$0.00	3 of 8 plans
California	8 of 12	2–4	$0.00	3 of 8 plans
New Jersey	7 of 12	2–4	$0.00	3 of 7 plans
North Carolina	7 of 12	2–4	$0.00	3 of 7 plans
Alabama and Tennessee	7 of 12	2–4	$0.00	3 of 7 plans
Illinois	7 of 12	2–4	$0.00	3 of 7 plans
Texas	7 of 12	2–4	$0.00	3 of 7 plans
Oklahoma	7 of 11	2–4	$0.00	3 of 7 plans
Kansas	7 of 12	2–4	$0.00	2 of 7 plans
New York	6 of 10	2–4	$0.00	3 of 6 plans
Delaware, DC and Maryland	6 of 10	2–4	$0.00	3 of 6 plans
South Carolina	6 of 11	2–4	$0.00	3 of 6 plans
Georgia	6 of 10	2–4	$0.00	3 of 6 plans
Ohio	6 of 10	2–4	$0.00	3 of 6 plans
Indiana and Kentucky	6 of 10	2–4	$0.00	3 of 6 plans
Wisconsin	6 of 10	2–4	$0.00	3 of 6 plans
Missouri	6 of 10	2–4	$0.00	3 of 6 plans
Arkansas	6 of 12	2–4	$0.00	3 of 6 plans
Mississippi	6 of 10	2–4	$0.00	3 of 6 plans
Louisiana	6 of 10	2–4	$0.00	3 of 6 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	6 of 11	2–4	$0.00	3 of 6 plans
New Mexico	6 of 11	2–4	$0.00	2 of 6 plans
Colorado	6 of 10	2–4	$0.00	3 of 6 plans
Arizona	6 of 10	2–4	$0.00	3 of 6 plans
Nevada	6 of 10	2–4	$0.00	3 of 6 plans
Oregon and Washington	6 of 10	2–4	$0.00	3 of 6 plans
Idaho and Utah	6 of 10	2–4	$0.00	3 of 6 plans
Maine and New Hampshire	5 of 9	2–4	$0.00	2 of 5 plans
Connecticut, Massachusetts, Rhode Island and Vermont	5 of 11	2–4	$0.00	2 of 5 plans
Virginia	5 of 9	2–4	$0.00	2 of 5 plans
Florida	5 of 10	2–4	$0.00	1 of 5 plans
Alaska	5 of 9	2–4	$0.00	2 of 5 plans
Hawaii	4 of 8	2–3	$0.00	1 of 4 plans
Puerto Rico	3 of 3	3–4	—	3 of 3 plans
American Samoa	1 of 1	3	—	1 of 1 plans
Guam	1 of 1	3	—	1 of 1 plans
Northern Mariana Islands	1 of 1	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	1 of 1 plans

Pennsylvania and West Virginia — 8 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6370	—	None
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6526	—	None
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6370	—	None
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.3789	—	None
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.3795	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4157	$28.6869 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5251	$3.156 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5727	$3.446 units	Quantity limit 6 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 — 8 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6491	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6569	—	None
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6491	—	None
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4160	$28.7069 units	Quantity limit 69 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.3554	—	None
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$0.3554	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5265	$3.166 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.4981	$2.996 units	Quantity limit 6 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 — 8 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7194	—	None
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7111	—	None
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7111	—	None
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	2Generic	$7.00	$17.50	$0.9655	—	None
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.9655	—	None
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4140	$28.5769 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5958	$3.576 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5362	$3.226 units	Quantity limit 6 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 Jersey — 7 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6981	—	None
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7042	—	None
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6981	—	None
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4189	$28.9069 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5124	$3.076 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5575	$3.346 units	Quantity limit 6 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$0.5971	—	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 — 7 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7153	—	None
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7361	—	None
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7153	—	None
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4116	$28.4069 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5713	$3.436 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.6100	$3.666 units	Quantity limit 6 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$0.7879	—	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 — 7 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7007	—	None
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7226	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7007	—	None
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4140	$28.5769 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5538	$3.326 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5830	$3.506 units	Quantity limit 6 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$0.7640	—	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 — 7 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7527	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7672	—	None
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7527	—	None
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4141	$28.5769 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5800	$3.486 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.6046	$3.636 units	Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.6807	—	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 — 7 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6865	—	None
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6646	—	None
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6646	—	None
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4137	$28.5569 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5264	$3.166 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5532	$3.326 units	Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.7501	—	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 — 7 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$2.00	$0.00	$0.5476	—	None
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.5682	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.5476	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4187	$28.8969 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5044	$3.036 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5305	$3.186 units	Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.8626	—	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 — 7 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6445	—	None
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6728	—	None
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6445	—	None
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4143	$28.5969 units	Quantity limit 69 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.8889	—	None
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6169	$3.706 units	Quantity limit 6 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$0.8859	—	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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6479	—	None
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6515	—	None
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6479	—	None
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4182	$28.8669 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5139	$3.086 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4770	$2.866 units	Quantity limit 6 per 30 days

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

Delaware, DC and Maryland — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6924	—	None
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6974	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6924	—	None
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4143	$28.5969 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5614	$3.376 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5161	$3.106 units	Quantity limit 6 per 30 days

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

South Carolina — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	2Generic	$2.00	$0.00	$0.7296	—	None
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7473	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7296	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4116	$28.4069 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5509	$3.316 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6046	$3.636 units	Quantity limit 6 per 30 days

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

Georgia — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6894	—	None
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7016	—	None
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6894	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4130	$28.5069 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5459	$3.286 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5815	$3.496 units	Quantity limit 6 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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6875	—	None
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7073	—	None
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6875	—	None
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4224	$29.1569 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5771	$3.466 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.6215	$3.736 units	Quantity limit 6 per 30 days

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

Indiana and Kentucky — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6969	—	None
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7180	—	None
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6969	—	None
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4174	$28.8069 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5978	$3.596 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6401	$3.846 units	Quantity limit 6 per 30 days

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

Wisconsin — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.8091	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.8193	—	None
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.8091	—	None
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4109	$28.3569 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6008	$3.606 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.5861	$3.526 units	Quantity limit 6 per 30 days

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

Missouri — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6635	—	None
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6959	—	None
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6635	—	None
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4131	$28.5069 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5696	$3.426 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6046	$3.636 units	Quantity limit 6 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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.5388	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.5772	—	None
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.5388	—	None
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4154	$28.6669 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5487	$3.296 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5327	$3.206 units	Quantity limit 6 per 30 days

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

Mississippi — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6049	—	None
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6299	—	None
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6049	—	None
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4143	$28.5969 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5469	$3.286 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5289	$3.176 units	Quantity limit 6 per 30 days

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

Louisiana — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6770	—	None
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7013	—	None
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6770	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4128	$28.4869 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5602	$3.366 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5341	$3.206 units	Quantity limit 6 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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6329	—	None
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6533	—	None
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6329	—	None
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4206	$29.0269 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5157	$3.096 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5310	$3.196 units	Quantity limit 6 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 — 6 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.8523	—	None
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.8692	—	None
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.8523	—	None
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4093	$28.2469 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6323	$3.796 units	Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.7961	—	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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.5630	—	None
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.5985	—	None
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.5630	—	None
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4212	$29.0669 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5825	$3.506 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5755	$3.456 units	Quantity limit 6 per 30 days

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

Arizona — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$3.00	$0.00	$0.7563	—	None
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7745	—	None
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7563	—	None
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4200	$28.9869 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6395	$3.846 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6115	$3.676 units	Quantity limit 6 per 30 days

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

Nevada — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7210	—	None
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7379	—	None
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7210	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4107	$28.3469 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5858	$3.516 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6243	$3.756 units	Quantity limit 6 per 30 days

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

Oregon and Washington — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6054	—	None
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.6310	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6054	—	None
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4124	$28.4669 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6046	$3.636 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5843	$3.516 units	Quantity limit 6 per 30 days

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

Idaho and Utah — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.5642	—	None
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.5860	—	None
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.5642	—	None
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4149	$28.6369 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5478	$3.296 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5564	$3.346 units	Quantity limit 6 per 30 days

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

Maine and New Hampshire — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6960	—	None
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7217	—	None
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6960	—	None
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4137	$28.5569 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6078	$3.656 units	Quantity limit 6 per 30 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7530	—	None
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7557	—	None
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7530	—	None
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4147	$28.6169 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6063	$3.646 units	Quantity limit 6 per 30 days

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

Virginia — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.6769	—	None
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7060	—	None
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.6769	—	None
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4157	$28.6869 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6133	$3.686 units	Quantity limit 6 per 30 days

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

Florida — 5 plans, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.7813	—	None
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	2Generic	$1.00	$0.00	$0.7693	—	None
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.7693	—	None
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4123	$28.4569 units	Quantity limit 69 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6691	—	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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$3.00	$0.00	$0.4521	—	None
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4521	—	None
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4521	—	None
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4177	$28.8269 units	Quantity limit 69 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5274	$3.166 units	Quantity limit 6 per 30 days

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

Hawaii — 4 plans, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	2Generic	$4.00	$0.00	$0.8546	—	None
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.8546	—	None
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.8546	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4089	$28.2169 units	Quantity limit 69 per 30 days

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

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4988	$34.4269 units	Quantity limit 69 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6205	$3.726 units	Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$0.6205	$3.726 units	Quantity limit 6 per 30 days

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4639	$32.0169 units	Quantity limit 69 per 30 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4639	$32.0169 units	Quantity limit 69 per 30 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4639	$32.0169 units	Quantity limit 69 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4136	$28.5469 units	Quantity limit 69 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