FLUOCINOLONE ACETONIDE .11 mg/118.28mL Oil

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Pennsylvania and West Virginia	11 of 12	2–4	$5.00	8 of 11 plans
Arkansas	11 of 12	3–4	—	8 of 11 plans
Connecticut, Massachusetts, Rhode Island and Vermont	10 of 11	3–4	$30.00	8 of 10 plans
New Jersey	10 of 12	4	—	7 of 10 plans
North Carolina	10 of 12	4	—	7 of 10 plans
Illinois	10 of 12	4	—	7 of 10 plans
Texas	10 of 12	4	—	7 of 10 plans
California	10 of 12	4	—	6 of 10 plans
New York	9 of 10	4	—	6 of 9 plans
Delaware, DC and Maryland	9 of 10	4	—	6 of 9 plans
South Carolina	9 of 11	4	—	6 of 9 plans
Georgia	9 of 10	4	—	6 of 9 plans
Alabama and Tennessee	9 of 12	4	—	6 of 9 plans
Michigan	9 of 12	4	—	6 of 9 plans
Ohio	9 of 10	4	—	6 of 9 plans
Indiana and Kentucky	9 of 10	4	—	6 of 9 plans
Wisconsin	9 of 10	4	—	6 of 9 plans
Missouri	9 of 10	4	—	6 of 9 plans
Mississippi	9 of 10	4	—	6 of 9 plans
Louisiana	9 of 10	4	—	6 of 9 plans
Oklahoma	9 of 11	4	—	6 of 9 plans
Kansas	9 of 12	4	—	7 of 9 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	9 of 11	4	—	6 of 9 plans
Colorado	9 of 10	4	—	6 of 9 plans
Arizona	9 of 10	4	—	6 of 9 plans
Nevada	9 of 10	4	—	6 of 9 plans
Oregon and Washington	9 of 10	4	—	6 of 9 plans
Idaho and Utah	9 of 10	4	—	6 of 9 plans
Maine and New Hampshire	8 of 9	4	—	6 of 8 plans
Virginia	8 of 9	4	—	6 of 8 plans
New Mexico	8 of 11	4	—	6 of 8 plans
Alaska	8 of 9	4	—	6 of 8 plans
Florida	7 of 10	4	—	6 of 7 plans
Hawaii	7 of 8	4	—	6 of 7 plans
Puerto Rico	3 of 3	4	—	none
American Samoa	1 of 1	4	—	none
Guam	1 of 1	4	—	none
Northern Mariana Islands	1 of 1	4	—	none
U.S. Virgin Islands	1 of 1	4	—	none

Pennsylvania and West Virginia — 11 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.1246	$15.82127 units	Quantity limit 118.28 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.1246	$15.82127 units	Quantity limit 118.28 per 28 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2437	$28.76118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6521	$76.95118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.6521	$76.95118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2458	$29.00118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.2685	$31.68118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4685	—	None
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.3695	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$0.2167	—	None
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2426	$28.63118 units	Quantity limit 118.28 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 — 11 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.3718	$43.87118 units	Quantity limit 118.28 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.3718	$43.87118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.5752	$67.87118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5752	$67.87118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4967	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2541	$29.98118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2597	$30.64118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6398	—	None
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3926	$46.33118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2512	$29.64118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$0.2210	—	None

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

Connecticut, Massachusetts, Rhode Island and Vermont — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2914	$34.39118 units	Quantity limit 118.28 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$0.2914	$34.39118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2613	$30.83118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6941	$81.90118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6941	$81.90118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.2750	$32.45118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.2622	$30.94118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2608	$30.77118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.3592	—	None
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$0.2275	—	None

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

New Jersey — 10 plans, 7 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	4Non-Preferred Drug	32%	—	$0.2630	$31.03118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6001	$70.81118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6001	$70.81118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.2636	$31.10118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4736	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.2989	$35.27118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3286	—	None
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2627	$31.00118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$0.2221	—	None
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$0.4275	$50.45118 units	Quantity limit 118.28 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.

North Carolina — 10 plans, 7 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	4Non-Preferred Drug	40%	40%	$0.6791	$80.13118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6791	$80.13118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2647	$31.23118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2688	$31.72118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6438	—	None
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3458	$40.80118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.4768	—	None
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2625	$30.98118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$0.2046	—	None
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$0.5522	$65.16118 units	Quantity limit 118.28 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.

Illinois — 10 plans, 7 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	4Non-Preferred Drug	31%	31%	$0.7370	$86.97118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7370	$86.97118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2770	$32.69118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.2797	$33.00118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.7897	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3442	$40.62118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$0.2119	—	None
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5184	—	None
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2755	$32.51118 units	Quantity limit 118.28 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5447	$64.27118 units	Quantity limit 118.28 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 — 10 plans, 7 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	4Non-Preferred Drug	29%	29%	$0.6986	$82.43118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6986	$82.43118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2657	$31.35118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2619	$30.90118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6067	—	None
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3504	$41.35118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4451	—	None
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2057	—	None
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2599	$30.67118 units	Quantity limit 118.28 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5363	$63.28118 units	Quantity limit 118.28 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 — 10 plans, 6 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	4Non-Preferred Drug	29%	29%	$0.3809	—	None
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6595	$77.82118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6595	$77.82118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5241	—	None
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3207	$37.84118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.2589	$30.55118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2572	$30.35118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$0.2094	—	None
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2562	$30.23118 units	Quantity limit 118.28 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	4Non-Preferred Drug	37%	37%	$0.4478	—	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 — 9 plans, 6 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	4Non-Preferred Drug	29%	29%	$0.2923	—	None
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5084	$59.99118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5085	$60.00118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.3912	—	None
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3078	$36.32118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.2516	$29.69118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.2526	$29.81118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$0.2146	—	None
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2511	$29.63118 units	Quantity limit 118.28 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 — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2572	$30.35118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2590	$30.56118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6677	$78.79118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6678	$78.80118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.3642	—	None
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5008	—	None
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2103	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3998	$47.18118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2563	$30.24118 units	Quantity limit 118.28 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 — 9 plans, 6 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	4Non-Preferred Drug	40%	40%	$0.7159	$84.48118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.7159	$84.48118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.2597	$30.64118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2639	$31.14118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5935	—	None
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3539	$41.76118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2044	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2575	$30.39118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4535	—	None

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

Georgia — 9 plans, 6 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	4Non-Preferred Drug	28%	28%	$0.6804	$80.29118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6804	$80.29118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2548	$30.07118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2588	$30.54118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5617	—	None
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3520	$41.54118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2527	$29.82118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.2059	—	None
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4349	—	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 — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2583	$30.48118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6586	$77.71118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6586	$77.71118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2628	$31.01118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6101	—	None
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.4635	—	None
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3609	$42.59118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2559	$30.20118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2069	—	None

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

Michigan — 9 plans, 6 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	4Non-Preferred Drug	28%	28%	$0.6122	$72.24118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6122	$72.24118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.3613	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2620	$30.92118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2638	$31.13118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5076	—	None
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3494	$41.23118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$0.2083	—	None
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2611	$30.81118 units	Quantity limit 118.28 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 — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.2547	$30.05118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7054	$83.24118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.7054	$83.24118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2569	$30.31118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5741	—	None
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3232	$38.14118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.4281	—	None
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2535	$29.91118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.2125	—	None

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

Indiana and Kentucky — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2601	$30.69118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6632	$78.26118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6632	$78.26118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2636	$31.10118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.2893	$34.14118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6312	—	None
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4720	—	None
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2583	$30.48118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2548	—	None

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

Wisconsin — 9 plans, 6 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	4Non-Preferred Drug	26%	26%	$0.5767	$68.05118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5767	$68.05118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4497	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2778	$32.78118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.2809	$33.15118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.2843	$33.55118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.6595	—	None
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2761	$32.58118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.2068	—	None

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

Missouri — 9 plans, 6 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	4Non-Preferred Drug	40%	40%	$0.6329	$74.68118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.6329	$74.68118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2577	$30.41118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2623	$30.95118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5709	—	None
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4381	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3701	$43.67118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2107	—	None
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2552	$30.11118 units	Quantity limit 118.28 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 — 9 plans, 6 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	4Non-Preferred Drug	29%	29%	$0.6332	$74.72118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6332	$74.72118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2617	$30.88118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.2685	$31.68118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5538	—	None
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.7211	—	None
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2581	$30.46118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3737	$44.10118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2179	—	None

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

Louisiana — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2727	$32.18118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6251	$73.76118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.6251	$73.76118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.2784	$32.85118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.2978	$35.14118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5093	—	None
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6934	—	None
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2697	$31.82118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.2048	—	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 — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$0.2643	$31.19118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6312	$74.48118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.6304	$74.39118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$0.2715	$32.04118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.7251	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2605	$30.74118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$0.2090	—	None
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5565	—	None
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.6488	$76.56118 units	Quantity limit 118.28 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 — 9 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4934	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7302	$86.16118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.7302	$86.16118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2574	$30.37118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.2627	$31.00118 units	Quantity limit 118.28 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$0.6372	$75.19118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.4001	$47.21118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2546	$30.04118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$0.2265	—	None

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 9 plans, 6 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	4Non-Preferred Drug	34%	—	$0.2589	$30.55118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6810	$80.36118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6810	$80.36118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2610	$30.80118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.3020	$35.64118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5044	—	None
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2577	$30.41118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.3617	—	None
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2202	—	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 — 9 plans, 6 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	4Non-Preferred Drug	40%	40%	$0.7333	$86.53118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$0.2630	$31.03118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.7333	$86.53118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2675	$31.57118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5683	—	None
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.7805	—	None
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3921	$46.27118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2606	$30.75118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$0.2130	—	None

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

Arizona — 9 plans, 6 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	4Non-Preferred Drug	32%	32%	$0.7679	$90.61118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7679	$90.61118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5398	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$0.2778	$32.78118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2814	$33.21118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.7798	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3718	$43.87118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2107	—	None
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2759	$32.56118 units	Quantity limit 118.28 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 — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2685	$31.68118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.7653	$90.31118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7653	$90.31118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$0.2726	$32.17118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.7418	—	None
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5270	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3858	$45.52118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.2083	—	None
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2663	$31.42118 units	Quantity limit 118.28 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 — 9 plans, 6 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	4Non-Preferred Drug	28%	28%	$0.7151	$84.38118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7151	$84.38118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4962	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2536	$29.92118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2566	$30.28118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.7152	—	None
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3727	$43.98118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2520	$29.74118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$0.2145	—	None

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

Idaho and Utah — 9 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2523	$29.77118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.6049	$71.38118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.2567	$30.29118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.6049	$71.38118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.2941	$34.70118 units	Quantity limit 118.28 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6368	—	None
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2500	$29.50118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4725	—	None
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$0.2128	—	None

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

Maine and New Hampshire — 8 plans, 6 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	4Non-Preferred Drug	27%	27%	$0.7637	$90.12118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7637	$90.12118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.4286	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2717	$32.06118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.2747	$32.41118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.5774	$68.13118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$0.2063	—	None
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2701	$31.87118 units	Quantity limit 118.28 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 — 8 plans, 6 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	4Non-Preferred Drug	31%	31%	$0.7050	$83.19118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7050	$83.19118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2576	$30.40118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$0.2619	$30.90118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.4030	$47.55118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2553	$30.13118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2051	—	None
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4615	—	None

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

New Mexico — 8 plans, 6 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	4Non-Preferred Drug	31%	31%	$0.7449	$87.90118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7449	$87.90118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6142	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2846	$33.58118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.2904	$34.27118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2816	$33.23118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2727	—	None
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.4395	$51.86118 units	Quantity limit 118.28 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 — 8 plans, 6 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	4Non-Preferred Drug	28%	28%	$0.7015	$82.78118 units	Quantity limit 118.28 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5291	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.2361	$27.86118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2407	$28.40118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7015	$82.78118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.4033	$47.59118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$0.2119	—	None
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2337	$27.58118 units	Quantity limit 118.28 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 — 7 plans, 6 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	4Non-Preferred Drug	28%	28%	$0.7020	$82.84118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7020	$82.84118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$0.2723	$32.13118 units	Quantity limit 118.28 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2697	$31.82118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3395	$40.06118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2683	$31.66118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2118	—	None

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

Hawaii — 7 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$0.2572	$30.35118 units	Quantity limit 118.28 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.3038	$35.85118 units	Quantity limit 118.28 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.7214	$85.13118 units	Quantity limit 118.28 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.7214	$85.13118 units	Quantity limit 118.28 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$0.2602	$30.70118 units	Quantity limit 118.28 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2556	$30.16118 units	Quantity limit 118.28 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$0.2042	—	None

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

Puerto Rico — 3 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6016	—	None
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$0.3771	—	None
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.1978	—	None

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

American Samoa — 1 plan

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.3520	—	None

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

Guam — 1 plan

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.2104	—	None

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

Northern Mariana Islands — 1 plan

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.3520	—	None

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

U.S. Virgin Islands — 1 plan

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$0.2091	—	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.

Coverage by region

Plan-by-plan detail