ELIGARD Kit (Leuprolide Acetate) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Kansas	11 of 12	3–4	—	11 of 11 plans
Connecticut, Massachusetts, Rhode Island and Vermont	10 of 11	3–4	—	10 of 10 plans
New Jersey	10 of 12	3–4	—	10 of 10 plans
Pennsylvania and West Virginia	10 of 12	3–4	—	10 of 10 plans
North Carolina	10 of 12	3–4	—	10 of 10 plans
Florida	10 of 10	3–4	—	10 of 10 plans
Alabama and Tennessee	10 of 12	3–4	—	10 of 10 plans
Illinois	10 of 12	3–4	—	10 of 10 plans
Arkansas	10 of 12	3–4	—	10 of 10 plans
Texas	10 of 12	3–4	—	10 of 10 plans
New Mexico	10 of 11	3–4	—	10 of 10 plans
Oklahoma	9 of 11	3–4	—	9 of 9 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	9 of 11	3–4	—	9 of 9 plans
Maine and New Hampshire	8 of 9	3–4	—	8 of 8 plans
New York	8 of 10	3–4	—	8 of 8 plans
Delaware, DC and Maryland	8 of 10	3–4	—	8 of 8 plans
Virginia	8 of 9	3–4	—	8 of 8 plans
South Carolina	8 of 11	3–4	—	8 of 8 plans
Georgia	8 of 10	3–4	—	8 of 8 plans
Michigan	8 of 12	3–4	—	8 of 8 plans
Ohio	8 of 10	3–4	—	8 of 8 plans
Indiana and Kentucky	8 of 10	3–4	—	8 of 8 plans
Wisconsin	8 of 10	3–4	—	8 of 8 plans
Missouri	8 of 10	3–4	—	8 of 8 plans
Mississippi	8 of 10	3–4	—	8 of 8 plans
Louisiana	8 of 10	3–4	—	8 of 8 plans
Colorado	8 of 10	3–4	—	8 of 8 plans
Arizona	8 of 10	3–4	—	8 of 8 plans
Nevada	8 of 10	3–4	—	8 of 8 plans
Oregon and Washington	8 of 10	3–4	—	8 of 8 plans
Idaho and Utah	8 of 10	3–4	—	8 of 8 plans
California	8 of 12	3–4	—	8 of 8 plans
Hawaii	8 of 8	3–4	—	8 of 8 plans
Alaska	8 of 9	3–4	—	8 of 8 plans
American Samoa	1 of 1	4	—	1 of 1 plans
Guam	1 of 1	4	—	1 of 1 plans
Northern Mariana Islands	1 of 1	4	—	1 of 1 plans
Puerto Rico	1 of 3	4	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	4	—	1 of 1 plans

Kansas — 11 plans, 11 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1543.5924	$416.770.27 units	Prior authorization Quantity limit 1 per 112 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1538.2843	$415.340.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$1813.1213	—	Prior authorization
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$1538.2843	$415.340.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 10 plans, 10 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1813.1213	—	Prior authorization
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1844.0448	—	Prior authorization
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1879.4382	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$1813.1213	—	Prior authorization
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	4Non-Preferred Drug	35%	35%	$1844.0448	—	Prior authorization

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

New Jersey — 10 plans, 10 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%	$1606.1657	—	Prior authorization
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1606.1657	—	Prior authorization
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1708.6787	—	Prior authorization
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$1708.6787	—	Prior authorization
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$1733.5000	$468.050.27 units	Prior authorization Quantity limit 1 per 112 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1831.7641	$494.580.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1708.6787	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$1831.7641	$494.580.27 units	Prior authorization Quantity limit 1 per 112 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$1733.5000	$468.050.27 units	Prior authorization Quantity limit 1 per 112 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 — 10 plans, 10 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1725.7904	—	Prior authorization
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1725.7904	—	Prior authorization
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1777.8502	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1725.7904	—	Prior authorization
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$1719.4660	$429.870.25 units	Step therapy Quantity limit 1 per 120 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$1730.3722	$432.590.25 units	Step therapy Quantity limit 1 per 120 days

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

North Carolina — 10 plans, 10 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1532.9194	$413.890.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$1532.9194	$413.890.27 units	Prior authorization Quantity limit 1 per 112 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	3Preferred Brand	25%	25%	$1656.2290	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1656.2290	—	Prior authorization
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1732.4821	—	Prior authorization
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1732.4821	—	Prior authorization
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$904.7667	$244.290.27 units	Prior authorization Quantity limit 1 per 112 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1732.4821	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$904.7667	$244.290.27 units	Prior authorization Quantity limit 1 per 112 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 — 10 plans, 10 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%	$1677.7700	—	Prior authorization
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1677.7700	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1709.8520	—	Prior authorization
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1709.8520	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$922.4733	$249.070.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1709.8520	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$922.4733	$249.070.27 units	Prior authorization Quantity limit 1 per 112 days

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

Illinois — 10 plans, 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	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$1575.2369	$425.310.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1553.3002	$419.390.27 units	Prior authorization Quantity limit 1 per 112 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 — 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	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1813.1213	—	Prior authorization
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$1854.9552	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$1854.9552	—	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.

Texas — 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	3Preferred Brand	25%	25%	$1644.4145	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1644.4145	—	Prior authorization
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1719.8634	—	Prior authorization
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1719.8634	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$1816.7489	$490.520.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$1625.2581	$438.820.27 units	Prior authorization Quantity limit 1 per 112 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1816.7489	$490.520.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1719.8634	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1625.2581	$438.820.27 units	Prior authorization Quantity limit 1 per 112 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 — 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	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$1813.1213	—	Prior authorization
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1553.3002	$419.390.27 units	Prior authorization Quantity limit 1 per 112 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1563.6244	$422.180.27 units	Prior authorization Quantity limit 1 per 112 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 — 9 plans, 9 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%	$2139.5000	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2139.5000	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$550.2800	$148.580.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$1698.3544	—	Prior authorization
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$1696.5463	$458.070.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$1696.5463	$458.070.27 units	Prior authorization Quantity limit 1 per 112 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$550.2800	$148.580.27 units	Prior authorization Quantity limit 1 per 112 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 — 9 plans, 9 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1777.8502	—	Prior authorization
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$1912.9400	$516.490.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 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%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization

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

New York — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1642.4354	—	Prior authorization
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1642.4354	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$1830.9691	$494.360.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$1749.5459	—	Prior authorization
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$1749.5459	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$1830.9691	$494.360.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1749.5459	—	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.

Delaware, DC and Maryland — 8 plans, 8 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1727.2626	—	Prior authorization
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1727.2626	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1727.2626	—	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.

Virginia — 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%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1698.3544	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 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%	$1691.1400	—	Prior authorization
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1691.1400	—	Prior authorization
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$1698.3544	—	Prior authorization
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1698.3544	—	Prior authorization
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	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.

Georgia — 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%	$1597.9100	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1597.9100	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1698.3544	—	Prior authorization
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1842.8937	$497.580.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$1842.8937	$497.580.27 units	Prior authorization Quantity limit 1 per 112 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 — 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%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1729.0693	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1729.0693	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1729.0693	—	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.

Ohio — 8 plans, 8 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%	$1597.9100	—	Prior authorization
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1597.9100	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$1698.3544	—	Prior authorization
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$1810.3721	$488.800.27 units	Prior authorization Quantity limit 1 per 112 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 — 8 plans, 8 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1725.4558	—	Prior authorization
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1725.4558	—	Prior authorization
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1777.8502	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1725.4558	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 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%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1879.4382	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 8 plans, 8 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	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.

Mississippi — 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%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 8 plans, 8 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1698.3544	—	Prior authorization
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 8 plans, 8 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1813.1213	—	Prior authorization
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 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%	$2139.5000	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2139.5000	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$1745.7819	—	Prior authorization
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1745.7819	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1696.5463	$458.070.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1696.5463	$458.070.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1745.7819	—	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.

Nevada — 8 plans, 8 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%	$1671.6200	—	Prior authorization
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1671.6200	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1770.6248	—	Prior authorization
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1770.6248	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1918.7776	$518.070.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$1918.7776	$518.070.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1770.6248	—	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.

Oregon and Washington — 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%	$1647.7700	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1647.7700	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1770.6248	—	Prior authorization
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1770.6248	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$1799.5315	$485.870.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1770.6248	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$1799.5315	$485.870.27 units	Prior authorization Quantity limit 1 per 112 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 — 8 plans, 8 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%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$1813.1213	—	Prior authorization
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1879.4382	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 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 — 8 plans, 8 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%	$1783.2800	—	Prior authorization
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1783.2800	—	Prior authorization
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1777.8502	—	Prior authorization
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$1815.5756	$490.210.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$1698.3544	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$1815.5756	$490.210.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1698.3544	—	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.

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$1813.1213	—	Prior authorization
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1879.4382	—	Prior authorization
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$1813.1213	—	Prior authorization
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days

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

Alaska — 8 plans, 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%	$1728.2910	—	Prior authorization
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$1728.2910	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$1813.1213	—	Prior authorization
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$1813.1213	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1879.4382	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$1879.7516	$507.530.27 units	Prior authorization Quantity limit 1 per 112 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1813.1213	—	Prior authorization

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$1886.9121	$509.470.27 units	Prior authorization Quantity limit 1 per 112 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	4Non-Preferred Drug	25%	25%	$1886.9121	$509.470.27 units	Prior authorization Quantity limit 1 per 112 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	4Non-Preferred Drug	25%	25%	$1886.9121	$509.470.27 units	Prior authorization Quantity limit 1 per 112 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 — 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)$145.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$1907.9370	$515.140.27 units	Prior authorization Quantity limit 1 per 112 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	4Non-Preferred Drug	25%	25%	$1886.9121	$509.470.27 units	Prior authorization Quantity limit 1 per 112 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.

ELIGARD Kit

Coverage by region

Plan-by-plan detail