NUBEQA 300 mg Tablet, Film Coated (Darolutamide) — Medicare Part D coverage and cost

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

New Jersey — 12 plans, 12 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	5Specialty Tier	25%	—	$120.0924	$1,441.1112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$117.4974	$1,409.9712 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$117.4974	$1,409.9712 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$120.0924	$1,441.1112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.5384	$1,422.4612 units	Prior authorization Quantity limit 12 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.2357	$1,430.8312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$128.4782	$1,541.7412 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.4810	$1,421.7712 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.0924	$1,441.1112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$128.4782	$1,541.7412 units	Prior authorization Quantity limit 12 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$119.2357	$1,430.8312 units	Prior authorization Quantity limit 12 per 30 days

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

Pennsylvania and West Virginia — 12 plans, 12 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	5Specialty Tier	25%	—	$119.4655	$1,433.5912 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.0431	$1,368.5212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.0431	$1,368.5212 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.4655	$1,433.5912 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.1175	$1,513.4112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.0055	$1,368.0712 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.0042	$1,368.0512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.1175	$1,513.4112 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.4655	$1,433.5912 units	Prior authorization Quantity limit 12 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$114.0498	$13,685.98120 units	Prior authorization Quantity limit 124 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$114.1109	$13,693.31120 units	Prior authorization Quantity limit 124 per 31 days

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

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.8109	$1,353.7312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.8109	$1,353.7312 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.7262	$1,436.7112 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.7262	$1,436.7112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$124.3641	$1,492.3712 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.7938	$1,353.5312 units	Prior authorization Quantity limit 12 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.9815	$1,511.7812 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.7928	$1,353.5112 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.7262	$1,436.7112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$124.3641	$1,492.3712 units	Prior authorization Quantity limit 12 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$125.9815	$1,511.7812 units	Prior authorization Quantity limit 12 per 30 days

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

Alabama and Tennessee — 12 plans, 12 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	5Specialty Tier	25%	—	$118.8440	$1,426.1312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.5940	$1,375.1312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.5940	$1,375.1312 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.8440	$1,426.1312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.3824	$1,504.5912 units	Prior authorization Quantity limit 12 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$118.3798	$1,420.5612 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.6135	$1,375.3612 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.6115	$1,375.3412 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.8440	$1,426.1312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.3824	$1,504.5912 units	Prior authorization Quantity limit 12 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$118.3798	$1,420.5612 units	Prior authorization Quantity limit 12 per 30 days

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

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$110.6678	$1,328.0112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$110.6678	$1,328.0112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.1607	$1,333.9312 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.9095	$1,426.9112 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.9095	$1,426.9112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$124.0030	$1,488.0412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.2607	$1,335.1312 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$124.0030	$1,488.0412 units	Prior authorization Quantity limit 12 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.7232	—	Prior authorization
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.9095	$1,426.9112 units	Prior authorization Quantity limit 12 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.7232	—	Prior authorization

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, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.9778	$1,355.7312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.9778	$1,355.7312 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.5165	$1,422.2012 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.5165	$1,422.2012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.5680	$1,506.8212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.0562	$1,356.6712 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.7722	$1,437.2712 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.5680	$1,506.8212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.0485	$1,356.5812 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.5165	$1,422.2012 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.7659	$1,437.1912 units	Prior authorization Quantity limit 12 per 30 days

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

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.0070	$1,368.0812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.0070	$1,368.0812 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.9536	$1,367.4412 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$122.1655	$1,465.9912 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.9536	$1,367.4412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.5006	$1,506.0112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.8826	—	Prior authorization
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.5006	$1,506.0112 units	Prior authorization Quantity limit 12 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$122.1655	$1,465.9912 units	Prior authorization Quantity limit 12 per 30 days

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

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.5190	$1,374.2312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.5190	$1,374.2312 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.9665	$1,427.6012 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.9665	$1,427.6012 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.0418	$1,356.5012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.6337	$1,507.6012 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.4007	$1,444.8112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.0411	$1,356.4912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.6337	$1,507.6012 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.9665	$1,427.6012 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.4014	$1,444.8212 units	Prior authorization Quantity limit 12 per 30 days

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

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$117.9126	$1,414.9512 units	Prior authorization Quantity limit 12 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$117.9126	$1,414.9512 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$105.8800	$1,270.5612 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$105.8800	$1,270.5612 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$105.8800	$1,270.5612 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.8264	$1,437.9212 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.8264	$1,437.9212 units	Prior authorization Quantity limit 12 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$117.9126	$1,414.9512 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.1640	$1,417.9712 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.8264	$1,437.9212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$118.1640	$1,417.9712 units	Prior authorization Quantity limit 12 per 30 days

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

California — 12 plans, 12 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	5Specialty Tier	25%	—	$112.4718	$1,349.6612 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1408	$1,345.6912 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1408	$1,345.6912 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.4808	$1,349.7712 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.0539	$1,428.6512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.1284	$1,501.5412 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.0539	$1,428.6512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.1284	$1,501.5412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.0539	$1,428.6512 units	Prior authorization Quantity limit 12 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$121.7863	$14,614.36120 units	Prior authorization Quantity limit 4 per 1 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$121.7863	$14,614.36120 units	Prior authorization Quantity limit 4 per 1 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.6562	$1,423.8712 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.4633	$1,337.5612 units	Prior authorization Quantity limit 12 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.4243	$1,445.0912 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.4633	$1,337.5612 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.1937	$1,514.3212 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.6562	$1,423.8712 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.6562	$1,423.8712 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.5010	$1,338.0112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.1937	$1,514.3212 units	Prior authorization Quantity limit 12 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.4243	$1,445.0912 units	Prior authorization Quantity limit 12 per 30 days

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

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1011	$1,345.2112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1011	$1,345.2112 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.6180	$1,423.4212 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.6180	$1,423.4212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1011	$1,345.2112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.0919	$1,513.1012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.0919	$1,513.1012 units	Prior authorization Quantity limit 12 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$124.8069	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.6180	$1,423.4212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1011	$1,345.2112 units	Prior authorization Quantity limit 12 per 30 days

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

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.4243	$1,433.0912 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.5029	$1,350.0312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.5029	$1,350.0312 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.4598	$1,349.5212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.8492	$1,510.1912 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.8492	$1,510.1912 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.4598	$1,349.5212 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.4431	$1,433.3212 units	Prior authorization Quantity limit 12 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.5177	$1,422.2112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.6272	$1,507.5312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.4556	$1,373.4712 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.4556	$1,373.4712 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.5177	$1,422.2112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.4720	$1,373.6612 units	Prior authorization Quantity limit 12 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$122.9627	$1,475.5512 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.5177	$1,422.2112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.4705	$1,373.6512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.6272	$1,507.5312 units	Prior authorization Quantity limit 12 per 30 days

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

New Mexico — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.1588	$1,333.9112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.1588	$1,333.9112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.1588	$1,333.9112 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$122.2973	$1,467.5712 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.2896	$1,419.4812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$122.2973	$1,467.5712 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$121.0938	$1,453.1312 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$121.3200	$1,455.8412 units	Prior authorization Quantity limit 12 per 30 days

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

New York — 10 plans, 10 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	5Specialty Tier	25%	—	$115.3229	$1,383.8712 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$115.4923	$1,385.9112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$115.4923	$1,385.9112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$115.3230	$1,383.8812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.1040	$1,513.2512 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.2897	$1,443.4812 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$120.2897	$1,443.4812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.1040	$1,513.2512 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.2897	$1,443.4812 units	Prior authorization Quantity limit 12 per 30 days

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

Delaware, DC and Maryland — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$117.4629	$1,409.5512 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$117.4629	$1,409.5512 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$110.1764	$1,322.1212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$110.1764	$1,322.1212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$110.2825	$1,323.3912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.2508	$1,515.0112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$110.2890	$1,323.4712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.2508	$1,515.0112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$117.4629	$1,409.5512 units	Prior authorization Quantity limit 12 per 30 days

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

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.9682	$1,343.6212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.9682	$1,343.6212 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.4142	$1,420.9712 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.4142	$1,420.9712 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.0258	$1,344.3112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.9058	$1,510.8712 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.4142	$1,420.9712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.9058	$1,510.8712 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.0221	$1,344.2712 units	Prior authorization Quantity limit 12 per 30 days

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

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.7306	$1,352.7712 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.7306	$1,352.7712 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$120.3720	$1,444.4612 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.3720	$1,444.4612 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$123.4229	$1,481.0712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.0343	$1,512.4112 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.3720	$1,444.4612 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.0343	$1,512.4112 units	Prior authorization Quantity limit 12 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$123.4229	$1,481.0712 units	Prior authorization Quantity limit 12 per 30 days

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

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.0092	$1,428.1112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1367	$1,345.6412 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1367	$1,345.6412 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.0092	$1,428.1112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1398	$1,345.6812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.1260	$1,513.5112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1388	$1,345.6712 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.0092	$1,428.1112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.1260	$1,513.5112 units	Prior authorization Quantity limit 12 per 30 days

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

Indiana and Kentucky — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$121.0230	$1,452.2812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.6590	$1,339.9112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.6590	$1,339.9112 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$121.0230	$1,452.2812 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8149	—	Prior authorization
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.7501	$1,341.0012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.7350	$1,508.8212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.7451	$1,340.9412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$121.0230	$1,452.2812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.7350	$1,508.8212 units	Prior authorization Quantity limit 12 per 30 days

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

Wisconsin — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.9763	$1,343.7212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.9763	$1,343.7212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1816	$1,346.1812 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.9448	$1,427.3412 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.9448	$1,427.3412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$127.0748	$1,524.9012 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1972	$1,346.3712 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.9448	$1,427.3412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$127.0748	$1,524.9012 units	Prior authorization Quantity limit 12 per 30 days

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

Missouri — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.4316	$1,373.1812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.4316	$1,373.1812 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.5455	$1,446.5512 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$120.5455	$1,446.5512 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.6585	$1,351.9012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$127.2178	$1,526.6112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.6393	$1,351.6712 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$127.2178	$1,526.6112 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.5455	$1,446.5512 units	Prior authorization Quantity limit 12 per 30 days

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

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.3588	$1,336.3112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.3588	$1,336.3112 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.0345	$1,428.4112 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.0345	$1,428.4112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.3588	$1,336.3112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.3588	$1,336.3112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.4778	$1,505.7312 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.0345	$1,428.4112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.4778	$1,505.7312 units	Prior authorization Quantity limit 12 per 30 days

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

Louisiana — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.4811	$1,433.7712 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.7259	$1,364.7112 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.7259	$1,364.7112 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.4811	$1,433.7712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$127.9816	$1,535.7812 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.5585	$1,374.7012 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.6070	$1,375.2812 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.4811	$1,433.7712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$127.9816	$1,535.7812 units	Prior authorization Quantity limit 12 per 30 days

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

Colorado — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1199	$1,345.4412 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.7635	$1,437.1612 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.1199	$1,345.4412 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.7635	$1,437.1612 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.3624	$1,348.3512 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.3764	$1,348.5212 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.7718	$1,521.2612 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.7635	$1,437.1612 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.7718	$1,521.2612 units	Prior authorization Quantity limit 12 per 30 days

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

Arizona — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.0484	$1,416.5812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.0484	$1,416.5812 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.1071	$1,417.2912 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.5877	$1,447.0512 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$120.5877	$1,447.0512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.2504	$1,515.0012 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.1174	$1,417.4112 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.2504	$1,515.0012 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.5877	$1,447.0512 units	Prior authorization Quantity limit 12 per 30 days

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

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$123.3232	$1,479.8812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$116.4400	$1,397.2812 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$116.4400	$1,397.2812 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$123.3232	$1,479.8812 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.6300	$1,423.5612 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$133.6423	$1,603.7112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.5100	$1,422.1212 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$133.6423	$1,603.7112 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$123.3232	$1,479.8812 units	Prior authorization Quantity limit 12 per 30 days

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

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.7413	$1,376.9012 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.7413	$1,376.9012 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.7202	$1,376.6412 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.8166	$1,425.8012 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.8166	$1,425.8012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.2795	$1,515.3512 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.7235	$1,376.6812 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.8166	$1,425.8012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.2795	$1,515.3512 units	Prior authorization Quantity limit 12 per 30 days

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

Idaho and Utah — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.9863	$1,427.8412 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.3614	$1,372.3412 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.9863	$1,427.8412 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.3614	$1,372.3412 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.3080	$1,371.7012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$125.6530	$1,507.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.9863	$1,427.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$114.3080	$1,371.7012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$125.6530	$1,507.8412 units	Prior authorization Quantity limit 12 per 30 days

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

Maine and New Hampshire — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.4937	$1,337.9212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.4937	$1,337.9212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.4839	$1,337.8112 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.4805	$1,433.7712 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$119.4805	$1,433.7712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.0919	$1,513.1012 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.0919	$1,513.1012 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$119.4805	$1,433.7712 units	Prior authorization Quantity limit 12 per 30 days

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

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.4196	$1,349.0412 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$112.4196	$1,349.0412 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.5436	$1,422.5212 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$118.5436	$1,422.5212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$123.8239	$1,485.8912 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$118.5436	$1,422.5212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$123.8239	$1,485.8912 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$113.3609	$1,360.3312 units	Prior authorization Quantity limit 12 per 30 days

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

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.2861	$1,443.4312 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$119.9433	$1,439.3212 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.2831	$1,515.4012 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$126.2831	$1,515.4012 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.2861	$1,443.4312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$130.9241	$1,571.0912 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$132.2445	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$130.9241	$1,571.0912 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$126.2831	$1,515.4012 units	Prior authorization Quantity limit 12 per 30 days

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

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.0919	$1,513.1012 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.1772	$1,442.1312 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$126.8468	—	Prior authorization
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.9100	$1,342.9212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$111.9100	$1,342.9212 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$120.1772	$1,442.1312 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$120.1772	$1,442.1312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$126.0919	$1,513.1012 units	Prior authorization Quantity limit 12 per 30 days

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

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	5Specialty Tier	25%	—	$121.0748	$1,452.9012 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.9962	$1,451.9512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$127.2297	$1,526.7612 units	Prior authorization Quantity limit 12 per 30 days

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

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	5Specialty Tier	25%	25%	$131.4229	$1,577.0712 units	Prior authorization Quantity limit 12 per 30 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$131.4229	$1,577.0712 units	Prior authorization Quantity limit 12 per 30 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$131.4229	$1,577.0712 units	Prior authorization Quantity limit 12 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$131.4229	$1,577.0712 units	Prior authorization Quantity limit 12 per 30 days

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

NUBEQA 300 mg Tablet, Film Coated

Coverage by region

Plan-by-plan detail