ONUREG 200 mg Tablet, Film Coated (Azacitidine) — Medicare Part D coverage and cost

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

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1815.8353	$27,237.5315 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1817.7264	$27,265.9015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1817.7264	$27,265.9015 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1815.8353	$27,237.5315 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1817.7544	$27,266.3215 units	Prior authorization Quantity limit 14 per 28 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1877.9585	$28,169.3815 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4627	$29,046.9415 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1817.7069	$27,265.6015 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1815.8353	$27,237.5315 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1936.4627	$29,046.9415 units	Prior authorization Quantity limit 14 per 28 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$1877.9585	$28,169.3815 units	Prior authorization Quantity limit 14 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.

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1814.7292	$27,220.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1729.1774	$25,937.6615 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1729.1774	$25,937.6615 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1814.7292	$27,220.9415 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1728.6509	$25,929.7615 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1728.6509	$25,929.7615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1814.7292	$27,220.9415 units	Prior authorization Quantity limit 14 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$1728.6509	$25,929.7615 units	Prior authorization Quantity limit 14 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$1729.1774	$25,937.6615 units	Prior authorization Quantity limit 14 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.

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1707.0210	$25,605.3115 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1707.0210	$25,605.3115 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1847.8103	$27,717.1515 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1847.8103	$27,717.1515 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1906.4791	$28,597.1915 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1707.0210	$25,605.3115 units	Prior authorization Quantity limit 14 per 28 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1859.9043	$27,898.5615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1707.0210	$25,605.3115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1847.8103	$27,717.1515 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1906.4791	$28,597.1915 units	Prior authorization Quantity limit 14 per 28 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1859.9043	$27,898.5615 units	Prior authorization Quantity limit 14 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.

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.5906	$27,578.8615 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1757.9430	$26,369.1515 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1757.9430	$26,369.1515 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1838.5906	$27,578.8615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1918.2981	$28,774.4715 units	Prior authorization Quantity limit 14 per 28 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$1770.0397	$26,550.6015 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1757.9430	$26,369.1515 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1757.9430	$26,369.1515 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1838.5906	$27,578.8615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1918.2981	$28,774.4715 units	Prior authorization Quantity limit 14 per 28 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$1770.0397	$26,550.6015 units	Prior authorization Quantity limit 14 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1971.3633	—	Prior authorization
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1971.3633	—	Prior authorization

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

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1703.6483	$25,554.7215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1703.6483	$25,554.7215 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1703.6483	$25,554.7215 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1778.3539	$26,675.3115 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1703.6483	$25,554.7215 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1778.3539	$26,675.3115 units	Prior authorization Quantity limit 14 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.

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1715.8400	$25,737.6015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1715.8400	$25,737.6015 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1715.8400	$25,737.6015 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1873.2892	$28,099.3415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1715.8400	$25,737.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1872.7105	$28,090.6615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1872.7105	$28,090.6615 units	Prior authorization Quantity limit 14 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1873.2892	$28,099.3415 units	Prior authorization Quantity limit 14 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.

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.2156	$26,148.2315 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.2156	$26,148.2315 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.2156	$26,148.2315 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1792.9363	$26,894.0415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.2156	$26,148.2315 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1792.9363	$26,894.0415 units	Prior authorization Quantity limit 14 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.

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1914.0181	$28,710.2715 units	Prior authorization Quantity limit 14 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1917.3880	$28,760.8215 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1917.3880	$28,760.8215 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 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.

California — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1703.9237	$25,558.8615 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1698.4384	$25,476.5815 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1698.4384	$25,476.5815 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1703.9237	$25,558.8615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1854.8523	$27,822.7815 units	Prior authorization Quantity limit 14 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1854.8523	$27,822.7815 units	Prior authorization Quantity limit 14 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1817.7155	$27,265.7315 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1843.2795	$27,649.1915 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1817.7155	$27,265.7315 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1817.7155	$27,265.7315 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1843.2795	$27,649.1915 units	Prior authorization Quantity limit 14 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.

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1786.0800	$26,791.2015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1786.0800	$26,791.2015 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1865.3131	$27,979.7015 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1865.3131	$27,979.7015 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1786.0800	$26,791.2015 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1913.8117	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1865.3131	$27,979.7015 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1786.0800	$26,791.2015 units	Prior authorization Quantity limit 14 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1723.1500	$25,847.2515 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1726.6240	$25,899.3615 units	Prior authorization Quantity limit 14 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 — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1856.1837	$27,842.7615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1965.8621	$29,487.9315 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1741.7372	$26,126.0615 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1741.7372	$26,126.0615 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1856.1837	$27,842.7615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1751.1224	$26,266.8415 units	Prior authorization Quantity limit 14 per 28 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1890.7184	$28,360.7815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1856.1837	$27,842.7615 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1750.6052	$26,259.0815 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1965.8621	$29,487.9315 units	Prior authorization Quantity limit 14 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.

New Mexico — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1891.5503	$28,373.2515 units	Prior authorization Quantity limit 14 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1907.4183	$28,611.2715 units	Prior authorization Quantity limit 14 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.

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1808.4600	$27,126.9015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1808.4600	$27,126.9015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1808.4600	$27,126.9015 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1808.4600	$27,126.9015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1887.6857	$28,315.2915 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1887.6857	$28,315.2915 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1887.6857	$28,315.2915 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1832.2337	$27,483.5115 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1832.2337	$27,483.5115 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1755.3176	$26,329.7615 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1755.3176	$26,329.7615 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1774.9538	$26,624.3115 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2005.1662	$30,077.4915 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1776.0990	$26,641.4915 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2005.1662	$30,077.4915 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1832.2337	$27,483.5115 units	Prior authorization Quantity limit 14 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.

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1706.5800	$25,598.7015 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1745.8227	$26,187.3415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1745.8227	$26,187.3415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1863.3504	$27,950.2615 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1863.3504	$27,950.2615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1870.0927	$28,051.3915 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1924.4049	$28,866.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1863.3504	$27,950.2615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1924.4049	$28,866.0715 units	Prior authorization Quantity limit 14 per 28 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1870.0927	$28,051.3915 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1820.3873	$27,305.8115 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1806.1500	$27,092.2515 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1806.1500	$27,092.2515 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1820.3873	$27,305.8115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1803.8300	$27,057.4515 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1803.8300	$27,057.4515 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1820.3873	$27,305.8115 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1840.5344	$27,608.0215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1712.1360	$25,682.0415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1712.1360	$25,682.0415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1840.5344	$27,608.0215 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1944.0481	$29,160.7215 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1712.1360	$25,682.0415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1929.5693	$28,943.5415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1712.1360	$25,682.0415 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1840.5344	$27,608.0215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1929.5693	$28,943.5415 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1701.9500	$25,529.2515 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1701.9500	$25,529.2515 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1701.9500	$25,529.2515 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1701.9500	$25,529.2515 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.6280	$26,154.4215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.6280	$26,154.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.7304	$27,670.9615 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1844.7304	$27,670.9615 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1757.0560	$26,355.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1979.8052	$29,697.0815 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1756.3160	$26,344.7415 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1979.8052	$29,697.0815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1844.7304	$27,670.9615 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.5329	$26,152.9915 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1743.5329	$26,152.9915 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1742.6629	$26,139.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1911.8821	$28,678.2315 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1742.6629	$26,139.9415 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1911.8821	$28,678.2315 units	Prior authorization Quantity limit 14 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 — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1658.4200	$24,876.3015 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1658.4200	$24,876.3015 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1945.0716	$29,176.0715 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1658.4200	$24,876.3015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1813.8562	$27,207.8415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1658.4200	$24,876.3015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1933.4940	$29,002.4115 units	Prior authorization Quantity limit 14 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 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 — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 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.

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 per 28 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2027.8401	$30,417.6015 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1844.3292	$27,664.9415 units	Prior authorization Quantity limit 14 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1936.4282	$29,046.4215 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$2007.5920	$30,113.8815 units	Prior authorization Quantity limit 14 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	5Specialty Tier	25%	—	$1838.8240	$27,582.3615 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1839.0725	$27,586.0915 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$2015.2394	$30,228.5915 units	Prior authorization Quantity limit 14 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	5Specialty Tier	25%	25%	$2015.2394	$30,228.5915 units	Prior authorization Quantity limit 14 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	5Specialty Tier	25%	25%	$2015.2394	$30,228.5915 units	Prior authorization Quantity limit 14 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	5Specialty Tier	25%	25%	$2015.2394	$30,228.5915 units	Prior authorization Quantity limit 14 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	5Specialty Tier	25%	25%	$2015.2394	$30,228.5915 units	Prior authorization Quantity limit 14 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.

ONUREG 200 mg Tablet, Film Coated

Coverage by region

Plan-by-plan detail