ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	4	—	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	4	—	12 of 12 plans
North Carolina	12 of 12	4	—	12 of 12 plans
Alabama and Tennessee	12 of 12	4	—	12 of 12 plans
Michigan	12 of 12	4	—	12 of 12 plans
Illinois	12 of 12	4	—	12 of 12 plans
Arkansas	12 of 12	4	—	12 of 12 plans
Texas	12 of 12	4	—	12 of 12 plans
Kansas	12 of 12	4	—	12 of 12 plans
California	12 of 12	4	—	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	4	—	11 of 11 plans
South Carolina	11 of 11	4	—	11 of 11 plans
Oklahoma	11 of 11	4	—	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	4	—	11 of 11 plans
New Mexico	11 of 11	4	—	11 of 11 plans
New York	10 of 10	4	—	10 of 10 plans
Delaware, DC and Maryland	10 of 10	4	—	10 of 10 plans
Georgia	10 of 10	4	—	10 of 10 plans
Florida	10 of 10	4	—	10 of 10 plans
Ohio	10 of 10	4	—	10 of 10 plans
Indiana and Kentucky	10 of 10	4	—	10 of 10 plans
Wisconsin	10 of 10	4	—	10 of 10 plans
Missouri	10 of 10	4	—	10 of 10 plans
Mississippi	10 of 10	4	—	10 of 10 plans
Louisiana	10 of 10	4	—	10 of 10 plans
Colorado	10 of 10	4	—	10 of 10 plans
Arizona	10 of 10	4	—	10 of 10 plans
Nevada	10 of 10	4	—	10 of 10 plans
Oregon and Washington	10 of 10	4	—	10 of 10 plans
Idaho and Utah	10 of 10	4	—	10 of 10 plans
Maine and New Hampshire	9 of 9	4	—	9 of 9 plans
Virginia	9 of 9	4	—	9 of 9 plans
Alaska	9 of 9	4	—	9 of 9 plans
Hawaii	8 of 8	4	—	8 of 8 plans
Puerto Rico	3 of 3	4	—	3 of 3 plans
American Samoa	1 of 1	4	—	1 of 1 plans
Guam	1 of 1	4	—	1 of 1 plans
Northern Mariana Islands	1 of 1	4	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	4	—	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	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.3431	$44.066 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$7.3431	$44.066 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$6.4197	—	Prior authorization
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$6.7362	$40.426 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$3.1145	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.6501	$9.906 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.8726	—	Prior authorization
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$3.1244	—	Prior authorization
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$6.7362	$40.426 units	Prior authorization Quantity limit 6 per 30 days

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

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	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.7141	$46.286 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$7.7436	$46.466 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.6062	$9.646 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$3.0195	—	Prior authorization
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$6.7653	—	Prior authorization
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$5.3668	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$3.0267	—	Prior authorization
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$5.4924	$494.3290 units	Prior authorization Quantity limit 93 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$5.4924	$494.3290 units	Prior authorization Quantity limit 93 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	4Non-Preferred Drug	40%	40%	$7.6106	$45.666 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$7.6106	$45.666 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.0034	—	Prior authorization
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.2025	—	Prior authorization
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$6.5107	$39.066 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5854	$9.516 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.9480	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$3.0536	—	Prior authorization
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$6.5107	$39.066 units	Prior authorization Quantity limit 6 per 30 days

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

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	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.4477	$44.696 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$7.4477	$44.696 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$2.9627	—	Prior authorization
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$9.5132	$57.086 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$8.7990	—	Prior authorization
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$6.7615	—	Prior authorization
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.8211	$10.936 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$3.0046	—	Prior authorization
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$9.5132	$57.086 units	Prior authorization Quantity limit 6 per 30 days

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

Michigan — 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	4Non-Preferred Drug	28%	28%	$7.4437	$44.666 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.4114	$44.476 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$4.9519	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$2.9896	—	Prior authorization
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$7.3378	—	Prior authorization
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.6444	$9.876 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$3.0563	—	Prior authorization
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$5.6274	$337.6460 units	Prior authorization Quantity limit 62 per 31 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	4Non-Preferred Drug	27%	27%	$5.6274	$337.6460 units	Prior authorization Quantity limit 62 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.

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	4Non-Preferred Drug	31%	31%	$7.9021	$47.416 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.9021	$47.416 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$3.1049	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$10.2204	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$8.5498	$51.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.6642	$9.996 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$3.1621	—	Prior authorization
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$6.0279	—	Prior authorization
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$7.7603	$46.566 units	Prior authorization Quantity limit 6 per 30 days

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

Arkansas — 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	4Non-Preferred Drug	26%	26%	$6.7327	$40.406 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.7327	$40.406 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$7.5695	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$2.4585	$14.756 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$8.4141	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$2.8985	—	Prior authorization
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5832	$9.506 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$2.9792	—	Prior authorization
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$2.4585	$14.756 units	Prior authorization Quantity limit 6 per 30 days

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

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	4Non-Preferred Drug	29%	29%	$7.6689	$46.016 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.6689	$46.016 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$8.0662	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$2.9744	—	Prior authorization
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5621	$9.376 units	Prior authorization Quantity limit 6 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$7.4522	$44.716 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$5.4402	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$3.0058	—	Prior authorization
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$6.9259	$41.566 units	Prior authorization Quantity limit 6 per 30 days

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

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	4Non-Preferred Drug	30%	30%	$11.8802	$71.286 units	Prior authorization Quantity limit 6 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$12.2772	$73.666 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.5389	—	Prior authorization
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.1347	$42.816 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$7.1347	$42.816 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$12.2772	$73.666 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.1851	$13.116 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$2.8781	—	Prior authorization
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$2.9239	—	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.

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	4Non-Preferred Drug	29%	29%	$5.0316	—	Prior authorization
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.5690	$45.416 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.5690	$45.416 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$7.8327	—	Prior authorization
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5236	$9.146 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$3.0218	—	Prior authorization
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$3.0289	—	Prior authorization
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	4Non-Preferred Drug	49%	49%	$9.9778	—	Prior authorization
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	4Non-Preferred Drug	37%	37%	$9.9778	—	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.

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	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.6845	$46.116 units	Prior authorization Quantity limit 6 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$13.0490	$78.296 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$7.6845	$46.116 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.5799	$9.486 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.1037	—	Prior authorization
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.7255	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$3.1074	—	Prior authorization
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	4Non-Preferred Drug	35%	35%	$13.0490	$78.296 units	Prior authorization Quantity limit 6 per 30 days

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

South Carolina — 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	4Non-Preferred Drug	40%	40%	$7.4709	$44.836 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$7.4709	$44.836 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$9.5598	—	Prior authorization
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5627	$9.386 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$3.0213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$3.0293	—	Prior authorization
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$5.5496	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.4353	—	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.

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	4Non-Preferred Drug	40%	40%	$8.2608	$49.566 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.8328	$47.006 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$7.8328	$47.006 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$10.5283	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$3.1427	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$3.1446	—	Prior authorization
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$5.9913	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$7.3917	$44.356 units	Prior authorization Quantity limit 6 per 30 days

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 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	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.2321	—	Prior authorization
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.0705	$42.426 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$7.0705	$42.426 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.9777	$11.876 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.5493	—	Prior authorization
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$9.0860	$54.526 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.9072	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$3.2642	—	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.

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	4Non-Preferred Drug	31%	31%	$7.7646	$46.596 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.7646	$46.596 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$8.3862	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$3.0916	—	Prior authorization
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$3.1424	—	Prior authorization
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5042	$9.036 units	Prior authorization Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$9.5053	$57.036 units	Prior authorization Quantity limit 6 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$10.1616	$60.976 units	Prior authorization Quantity limit 6 per 30 days

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

New 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	4Non-Preferred Drug	29%	29%	$4.6899	—	Prior authorization
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.0258	$42.156 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$7.0258	$42.156 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$5.9122	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$3.1411	—	Prior authorization
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.9039	$11.426 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$3.1586	—	Prior authorization
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Delaware, DC and Maryland — 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	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.7615	$46.576 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.7615	$46.576 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.3390	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$3.3581	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$7.6926	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$3.3790	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.9768	$11.866 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Georgia — 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	4Non-Preferred Drug	28%	28%	$7.5105	$45.066 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.5105	$45.066 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$7.3501	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.0723	—	Prior authorization
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5688	$9.416 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$3.1115	—	Prior authorization
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$6.1666	—	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.

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	4Non-Preferred Drug	28%	28%	$7.6339	$45.806 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.6339	$45.806 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5818	$9.496 units	Prior authorization Quantity limit 6 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.3609	$38.176 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.0041	—	Prior authorization
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$3.0119	—	Prior authorization
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$6.3609	$38.176 units	Prior authorization Quantity limit 6 per 30 days

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

Ohio — 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	4Non-Preferred Drug	31%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.6946	$46.176 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$7.6946	$46.176 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$8.3047	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.1933	—	Prior authorization
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5617	$9.376 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$6.5435	—	Prior authorization
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$3.2305	—	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.

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	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.6757	$46.056 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$7.6847	$46.116 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.5631	$9.386 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$8.3580	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$3.1984	—	Prior authorization
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.8024	—	Prior authorization
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$3.2921	—	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.

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	4Non-Preferred Drug	26%	26%	$6.8643	$41.196 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.8643	$41.196 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$6.4863	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$2.9898	—	Prior authorization
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.7292	$10.386 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$10.3471	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$3.0000	—	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.

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	4Non-Preferred Drug	40%	40%	$7.6806	$46.086 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$7.6806	$46.086 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$8.4041	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$3.1289	—	Prior authorization
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.8636	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.0288	$12.176 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$3.1389	—	Prior authorization
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Mississippi — 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	4Non-Preferred Drug	29%	29%	$6.4193	$38.526 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.4193	$38.526 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$6.2056	—	Prior authorization
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$7.1464	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$2.8999	—	Prior authorization
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.7399	$10.446 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$2.9151	—	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.

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	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.2381	$43.436 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$7.2381	$43.436 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$3.0483	—	Prior authorization
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.8896	$11.346 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$7.6334	—	Prior authorization
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$9.7191	—	Prior authorization
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$3.0553	—	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.

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	4Non-Preferred Drug	40%	40%	$7.9439	$47.666 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$7.9439	$47.666 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$8.5697	—	Prior authorization
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$12.6674	—	Prior authorization
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.4968	$8.986 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.0563	—	Prior authorization
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$3.0665	—	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.

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	4Non-Preferred Drug	32%	32%	$7.8517	$47.116 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.8517	$47.116 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$6.1955	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$3.0123	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$11.5813	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.5578	$9.356 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$3.0497	—	Prior authorization
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Nevada — 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	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.9800	$47.886 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.9800	$47.886 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$7.2570	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.1658	—	Prior authorization
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$4.6869	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.4877	$8.936 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$3.1662	—	Prior authorization
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Oregon and Washington — 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	4Non-Preferred Drug	28%	28%	$7.7811	$46.696 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.7811	$46.696 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.7444	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$2.8252	—	Prior authorization
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$9.8532	—	Prior authorization
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.0057	$12.036 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$2.9914	—	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.

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	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.2531	$37.526 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$6.2531	$37.526 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$2.6298	$15.786 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$7.2956	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$2.7782	—	Prior authorization
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$6.1012	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$2.8555	—	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.

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	4Non-Preferred Drug	27%	27%	$7.5045	$45.036 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.5045	$45.036 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5.0304	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$3.0350	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.4658	$14.796 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$3.0418	—	Prior authorization
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Virginia — 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	4Non-Preferred Drug	31%	31%	$7.6954	$46.176 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.6954	$46.176 units	Prior authorization Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.8646	—	Prior authorization
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.8525	$11.126 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$3.8823	—	Prior authorization
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$6.2426	—	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.

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	4Non-Preferred Drug	28%	28%	$24.5688	$147.416 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$24.0804	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$24.5688	$147.416 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$18.2346	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$9.7588	$58.556 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$18.2354	—	Prior authorization
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days

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

Hawaii — 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	4Non-Preferred Drug	38%	—	$4.8749	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$10.1046	$60.636 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.4113	$38.476 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$6.4148	$38.496 units	Prior authorization Quantity limit 6 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.0500	$102.306 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.9130	—	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.

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	4Non-Preferred Drug	31%	31%	$11.6225	—	Prior authorization
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$6.0700	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$5.3892	—	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.

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	4Non-Preferred Drug	25%	25%	$5.1432	—	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.

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	4Non-Preferred Drug	25%	25%	$5.1432	—	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.

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	4Non-Preferred Drug	25%	25%	$5.1432	—	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.

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	4Non-Preferred Drug	25%	25%	$5.1432	—	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.

Coverage by region

Plan-by-plan detail