AIMOVIG 140 mg/mL Injection, Solution (Erenumab-Aooe) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Pennsylvania and West Virginia	9 of 12	3	—	9 of 9 plans
Michigan	9 of 12	3	—	9 of 9 plans
Arkansas	9 of 12	3	—	9 of 9 plans
California	9 of 12	3	—	9 of 9 plans
Connecticut, Massachusetts, Rhode Island and Vermont	8 of 11	3	$30.00	8 of 8 plans
New Jersey	8 of 12	3	—	8 of 8 plans
North Carolina	8 of 12	3	$45.00	8 of 8 plans
South Carolina	8 of 11	3	—	8 of 8 plans
Illinois	8 of 12	3	—	8 of 8 plans
Texas	8 of 12	3	—	8 of 8 plans
New York	7 of 10	3	—	7 of 7 plans
Delaware, DC and Maryland	7 of 10	3	—	7 of 7 plans
Georgia	7 of 10	3	—	7 of 7 plans
Alabama and Tennessee	7 of 12	3	—	7 of 7 plans
Ohio	7 of 10	3	—	7 of 7 plans
Indiana and Kentucky	7 of 10	3	—	7 of 7 plans
Wisconsin	7 of 10	3	—	7 of 7 plans
Missouri	7 of 10	3	—	7 of 7 plans
Mississippi	7 of 10	3	—	7 of 7 plans
Louisiana	7 of 10	3	—	7 of 7 plans
Oklahoma	7 of 11	3	—	7 of 7 plans
Kansas	7 of 12	3	—	7 of 7 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	7 of 11	3	—	7 of 7 plans
Colorado	7 of 10	3	—	7 of 7 plans
Arizona	7 of 10	3	—	7 of 7 plans
Nevada	7 of 10	3	—	7 of 7 plans
Oregon and Washington	7 of 10	3	—	7 of 7 plans
Idaho and Utah	7 of 10	3	—	7 of 7 plans
Maine and New Hampshire	6 of 9	3	—	6 of 6 plans
Virginia	6 of 9	3	—	6 of 6 plans
New Mexico	6 of 11	3	—	6 of 6 plans
Alaska	6 of 9	3	—	6 of 6 plans
Florida	5 of 10	3	—	5 of 5 plans
Hawaii	5 of 8	3	—	5 of 5 plans
Puerto Rico	3 of 3	3	—	3 of 3 plans
American Samoa	1 of 1	3	—	1 of 1 plans
Guam	1 of 1	3	—	1 of 1 plans
Northern Mariana Islands	1 of 1	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	1 of 1 plans

Pennsylvania and West Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$714.5070	$714.511 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$714.5070	$714.511 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.2448	$789.241 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$791.0297	$791.031 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$731.5667	$731.571 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$731.5195	$731.521 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$791.0297	$791.031 unit	Prior authorization Quantity limit 1 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	3Preferred Brand	25%	25%	$735.4218	$735.421 unit	Prior authorization Quantity limit 1 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$731.2103	$731.211 unit	Prior authorization Quantity limit 1 per 28 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 — 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	3Preferred Brand	25%	25%	$714.3295	$714.331 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$714.3295	$714.331 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$726.2732	$726.271 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$796.0701	$796.071 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$725.7211	$725.721 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2325	$789.231 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$796.0701	$796.071 unit	Prior authorization Quantity limit 1 per 28 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$751.5071	$751.511 unit	Prior authorization Quantity limit 3 per 84 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$751.5071	$751.511 unit	Prior authorization Quantity limit 3 per 84 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 — 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	3Preferred Brand	25%	25%	$718.3635	$718.361 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$718.3635	$718.361 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$730.5420	$730.541 unit	Prior authorization Quantity limit 1 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$761.5822	$761.581 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$729.8628	$729.861 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$804.9473	$804.951 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.7139	$789.711 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$804.9473	$804.951 unit	Prior authorization Quantity limit 1 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$761.5822	$761.581 unit	Prior authorization Quantity limit 1 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 — 9 plans, 9 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	3Preferred Brand	25%	25%	$737.1863	$737.191 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$715.9295	$715.931 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$715.9295	$715.931 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$737.5614	$737.561 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.1988	$789.201 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$794.2704	$794.271 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$794.2704	$794.271 unit	Prior authorization Quantity limit 1 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$767.6969	$767.701 unit	Prior authorization Quantity limit 1 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$767.6969	$767.701 unit	Prior authorization Quantity limit 1 per 28 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$713.2103	$713.211 unit	Prior authorization Quantity limit 1 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$747.5960	$747.601 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$713.2103	$713.211 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.1865	$789.191 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$795.8304	$795.831 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$737.6139	$737.611 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$795.8304	$795.831 unit	Prior authorization Quantity limit 1 per 28 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$747.5960	$747.601 unit	Prior authorization Quantity limit 1 per 30 days

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

New Jersey — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$712.4526	$712.451 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$712.4526	$712.451 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$732.1147	$732.111 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$795.4635	$795.461 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2808	$789.281 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$732.0576	$732.061 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$795.4635	$795.461 unit	Prior authorization Quantity limit 1 per 28 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$766.1687	$766.171 unit	Prior authorization Quantity limit 1 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 — 8 plans, 8 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	3Preferred Brand	25%	25%	$720.3470	$720.351 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$720.3470	$720.351 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$801.0980	$801.101 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$737.6942	$737.691 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.1968	$789.201 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$738.5480	$738.551 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$801.0980	$801.101 unit	Prior authorization Quantity limit 1 per 28 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$775.9876	$775.991 unit	Prior authorization Quantity limit 1 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 — 8 plans, 8 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	3Preferred Brand	25%	25%	$719.5518	$719.551 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$719.5518	$719.551 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$739.7451	$739.751 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2655	$789.271 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$795.6464	$795.651 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$795.6464	$795.651 unit	Prior authorization Quantity limit 1 per 28 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$753.7604	$753.761 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$741.7646	$741.761 unit	Prior authorization Quantity limit 1 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 — 8 plans, 8 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	3Preferred Brand	25%	25%	$722.4041	$722.401 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$722.4041	$722.401 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$803.2950	$803.291 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$741.3518	$741.351 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.3490	$789.351 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$803.2950	$803.291 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$741.5501	$741.551 unit	Prior authorization Quantity limit 1 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$761.4829	$761.481 unit	Prior authorization Quantity limit 1 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 — 8 plans, 8 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	3Preferred Brand	25%	25%	$717.8446	$717.841 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$717.8446	$717.841 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$733.4921	$733.491 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$800.8062	$800.811 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2923	$789.291 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$733.5928	$733.591 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$800.8062	$800.811 unit	Prior authorization Quantity limit 1 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$763.4561	$763.461 unit	Prior authorization Quantity limit 1 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 — 7 plans, 7 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	3Preferred Brand	25%	25%	$728.6998	$728.701 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$713.1654	$713.171 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$713.1654	$713.171 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$729.1689	$729.171 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$793.2712	$793.271 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.4112	$789.411 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$793.2712	$793.271 unit	Prior authorization Quantity limit 1 per 28 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$715.1996	$715.201 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$715.1996	$715.201 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$735.2197	$735.221 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$796.1457	$796.151 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$735.1848	$735.181 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$796.1457	$796.151 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2166	$789.221 unit	Prior authorization Quantity limit 1 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 — 7 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	3Preferred Brand	25%	25%	$723.8222	$723.821 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$723.8222	$723.821 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$735.9741	$735.971 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$799.7083	$799.711 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.6563	$789.661 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$799.7083	$799.711 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$738.7413	$738.741 unit	Prior authorization Quantity limit 1 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 — 7 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	3Preferred Brand	25%	25%	$723.5726	$723.571 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$723.5726	$723.571 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$801.2188	$801.221 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$736.7922	$736.791 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$738.4658	$738.471 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2578	$789.261 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$801.2188	$801.221 unit	Prior authorization Quantity limit 1 per 28 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$729.6467	$729.651 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$729.6467	$729.651 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$738.8400	$738.841 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$792.3622	$792.361 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2421	$789.241 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$740.8226	$740.821 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$792.3622	$792.361 unit	Prior authorization Quantity limit 1 per 28 days

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

Indiana and Kentucky — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$725.6417	$725.641 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$725.6417	$725.641 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.3400	$789.341 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$734.8383	$734.841 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$801.1710	$801.171 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$736.1963	$736.201 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$801.1710	$801.171 unit	Prior authorization Quantity limit 1 per 28 days

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

Wisconsin — 7 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	3Preferred Brand	25%	25%	$719.2201	$719.221 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$719.2201	$719.221 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$732.0932	$732.091 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$806.9278	$806.931 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.3814	$789.381 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$731.9866	$731.991 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$806.9278	$806.931 unit	Prior authorization Quantity limit 1 per 28 days

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

Missouri — 7 plans, 7 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	3Preferred Brand	25%	25%	$722.3162	$722.321 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$722.3162	$722.321 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$736.5619	$736.561 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$804.0224	$804.021 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$736.5160	$736.521 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.9643	$789.961 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$804.0224	$804.021 unit	Prior authorization Quantity limit 1 per 28 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 — 7 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	3Preferred Brand	25%	25%	$722.7795	$722.781 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$722.7795	$722.781 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$734.9989	$735.001 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$733.9902	$733.991 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$802.7816	$802.781 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.1744	$789.171 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$802.7816	$802.781 unit	Prior authorization Quantity limit 1 per 28 days

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

Louisiana — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$718.7463	$718.751 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$718.7463	$718.751 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$804.7326	$804.731 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.1621	$789.161 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$733.9960	$734.001 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$734.0824	$734.081 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$804.7326	$804.731 unit	Prior authorization Quantity limit 1 per 28 days

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

Oklahoma — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$730.1771	$730.181 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$730.1771	$730.181 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$747.5293	$747.531 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$803.1808	$803.181 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$803.1808	$803.181 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$747.3752	$747.381 unit	Prior authorization Quantity limit 1 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$767.2359	$767.241 unit	Prior authorization Quantity limit 1 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 — 7 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	3Preferred Brand	25%	25%	$743.1547	$743.151 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$733.5859	$733.591 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$733.5859	$733.591 unit	Prior authorization Quantity limit 1 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$778.2322	$778.231 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$791.2169	$791.221 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$798.8144	$798.811 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$798.8144	$798.811 unit	Prior authorization Quantity limit 1 per 28 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$798.1194	$798.121 unit	Prior authorization Quantity limit 1 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$726.3651	$726.371 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$726.3651	$726.371 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.8831	$789.881 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$729.6723	$729.671 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$729.9544	$729.951 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$798.1194	$798.121 unit	Prior authorization Quantity limit 1 per 28 days

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

Colorado — 7 plans, 7 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	3Preferred Brand	25%	25%	$733.5841	$733.581 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$733.5841	$733.581 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$741.8587	$741.861 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$739.5709	$739.571 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.7392	$789.741 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$805.7896	$805.791 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$805.7896	$805.791 unit	Prior authorization Quantity limit 1 per 28 days

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

Arizona — 7 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	3Preferred Brand	25%	25%	$730.9457	$730.951 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$730.9457	$730.951 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$746.5150	$746.511 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$803.8521	$803.851 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$745.7199	$745.721 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2699	$789.271 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$803.8521	$803.851 unit	Prior authorization Quantity limit 1 per 28 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$726.3771	$726.381 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$726.3771	$726.381 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$739.1577	$739.161 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$804.3454	$804.351 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$740.0018	$740.001 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.1806	$789.181 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$804.3454	$804.351 unit	Prior authorization Quantity limit 1 per 28 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 — 7 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	3Preferred Brand	25%	25%	$730.2372	$730.241 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$730.2372	$730.241 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$738.7392	$738.741 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$799.2673	$799.271 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$737.9139	$737.911 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2822	$789.281 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$799.2673	$799.271 unit	Prior authorization Quantity limit 1 per 28 days

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

Idaho and Utah — 7 plans, 7 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	3Preferred Brand	25%	25%	$721.7731	$721.771 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$721.7731	$721.771 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$789.2464	$789.251 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$727.7103	$727.711 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$797.8371	$797.841 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$729.4125	$729.411 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$797.8371	$797.841 unit	Prior authorization Quantity limit 1 per 28 days

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

Maine and New Hampshire — 6 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	3Preferred Brand	25%	25%	$718.8889	$718.891 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$718.8889	$718.891 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$733.1324	$733.131 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$798.4358	$798.441 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2036	$789.201 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$798.4358	$798.441 unit	Prior authorization Quantity limit 1 per 28 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 — 6 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	3Preferred Brand	25%	25%	$721.4650	$721.471 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$721.4650	$721.471 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$798.5860	$798.591 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2133	$789.211 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$798.5860	$798.591 unit	Prior authorization Quantity limit 1 per 28 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$741.4525	$741.451 unit	Prior authorization Quantity limit 1 per 30 days

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

New Mexico — 6 plans, 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	3Preferred Brand	25%	25%	$723.5026	$723.501 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$723.5026	$723.501 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$737.6567	$737.661 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$810.6404	$810.641 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$810.6404	$810.641 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2118	$789.211 unit	Prior authorization Quantity limit 1 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 — 6 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	3Preferred Brand	25%	25%	$735.0929	$735.091 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$738.5228	$738.521 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$735.0929	$735.091 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$800.2055	$800.211 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$790.4191	$790.421 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$800.2055	$800.211 unit	Prior authorization Quantity limit 1 per 28 days

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

Florida — 5 plans, 5 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	3Preferred Brand	25%	25%	$717.9517	$717.951 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$717.9517	$717.951 unit	Prior authorization Quantity limit 1 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$789.2111	$789.211 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$800.1340	$800.131 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$800.1340	$800.131 unit	Prior authorization Quantity limit 1 per 28 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 — 5 plans, 5 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	3Preferred Brand	16%	16%	$808.8885	$808.891 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$790.8846	$790.881 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$720.9669	$720.971 unit	Prior authorization Quantity limit 1 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$720.9669	$720.971 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$808.8885	$808.891 unit	Prior authorization Quantity limit 1 per 28 days

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

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$742.6653	$742.671 unit	Prior authorization Quantity limit 1 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$742.3991	$742.401 unit	Prior authorization Quantity limit 1 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$791.7893	$791.791 unit	Prior authorization Quantity limit 1 per 28 days

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$817.7540	$817.751 unit	Prior authorization Quantity limit 1 per 28 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$817.7540	$817.751 unit	Prior authorization Quantity limit 1 per 28 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$817.7540	$817.751 unit	Prior authorization Quantity limit 1 per 28 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$817.7540	$817.751 unit	Prior authorization Quantity limit 1 per 28 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.

AIMOVIG 140 mg/mL Injection, Solution

Coverage by region

Plan-by-plan detail