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
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	30%	$378.8020	$378.801 unit	Prior authorization Quantity limit 1 per 28 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	40%	40%	$377.1058	$377.111 unit	Prior authorization Quantity limit 1 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$453.2803	—	Prior authorization
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$377.1058	$377.111 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 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)$8.40/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$453.2803	—	Prior authorization
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	32%	$449.4513	—	Prior authorization
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$449.8851	$449.891 unit	Prior authorization Quantity limit 1 per 28 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$453.2803	—	Prior authorization
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$449.8851	$449.891 unit	Prior authorization Quantity limit 1 per 28 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	4Non-Preferred Drug	35%	35%	$449.4513	—	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
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$431.1647	—	Prior authorization
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$408.4301	—	Prior authorization
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$408.4301	—	Prior authorization
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$431.1647	—	Prior authorization
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$324.1184	$324.121 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$459.1521	$459.151 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$431.1647	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$459.1521	$459.151 unit	Prior authorization Quantity limit 1 per 28 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$324.1184	$324.121 unit	Prior authorization Quantity limit 1 per 28 days

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

Pennsylvania and West Virginia — 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)$6.60/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$432.0443	—	Prior authorization
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$432.0443	—	Prior authorization
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$432.0443	—	Prior authorization
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$429.8766	$429.881 unit	Step therapy Quantity limit 1 per 30 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$432.6030	$432.601 unit	Step therapy Quantity limit 1 per 30 days

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

North Carolina — 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%	$398.4000	—	Prior authorization
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$398.4000	—	Prior authorization
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$435.6550	—	Prior authorization
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$435.6550	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$340.2788	$340.281 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$435.6550	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$340.2788	$340.281 unit	Prior authorization Quantity limit 1 per 28 days

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

Florida — 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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$411.6456	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$411.6456	—	Prior authorization
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$434.9216	—	Prior authorization
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$434.9216	—	Prior authorization
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$401.8463	$401.851 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$466.3285	$466.331 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$434.9216	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$466.3285	$466.331 unit	Prior authorization Quantity limit 1 per 28 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$401.8463	$401.851 unit	Prior authorization Quantity limit 1 per 28 days

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

Alabama and Tennessee — 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 · $0 with full Extra Help	4Non-Preferred Drug	34%	—	$426.8471	—	Prior authorization
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$422.7900	—	Prior authorization
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$422.7900	—	Prior authorization
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$426.8471	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$88.6725	$88.671 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$426.8471	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$88.6725	$88.671 unit	Prior authorization Quantity limit 1 per 28 days

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

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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$417.9200	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$417.9200	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	34%	—	$442.6562	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$442.6562	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$442.1716	$442.171 unit	Prior authorization Quantity limit 1 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$428.9763	$428.981 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$442.1716	$442.171 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$442.6562	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$428.9763	$428.981 unit	Prior authorization Quantity limit 1 per 28 days

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

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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	34%	—	$424.5886	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$424.5886	—	Prior authorization
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$438.5023	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$424.5886	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$438.5023	—	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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$403.1894	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$403.1894	—	Prior authorization
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$428.8591	—	Prior authorization
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$428.8591	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$458.9518	$458.951 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$414.3712	$414.371 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$458.9518	$458.951 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$428.8591	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$413.8256	$413.831 unit	Prior authorization Quantity limit 1 per 28 days

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

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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	43%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$453.2803	—	Prior authorization
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$382.5689	$382.571 unit	Prior authorization Quantity limit 1 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$384.9522	$384.951 unit	Prior authorization Quantity limit 1 per 28 days

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

Oklahoma — 9 plans, 9 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 · $0 with full Extra Help	4Non-Preferred Drug	40%	40%	$247.9313	$247.931 unit	Prior authorization Quantity limit 1 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	—	$453.2803	—	Prior authorization
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$247.9313	$247.931 unit	Prior authorization Quantity limit 1 per 28 days

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

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
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	34%	—	$442.6562	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$476.9866	$476.991 unit	Prior authorization Quantity limit 1 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$422.7900	—	Prior authorization
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$422.7900	—	Prior authorization
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$442.6562	—	Prior authorization
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$486.6000	$486.601 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$442.6562	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$476.9866	$476.991 unit	Prior authorization Quantity limit 1 per 28 days

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

Maine and New Hampshire — 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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	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%	$416.8230	—	Prior authorization
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$416.8230	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$428.1150	—	Prior authorization
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$428.1150	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$428.1150	—	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
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$424.9650	—	Prior authorization
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$424.9650	—	Prior authorization
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$421.5717	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$421.5717	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$454.8538	$454.851 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$454.8538	$454.851 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$424.9650	—	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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$399.4900	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$399.4900	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$424.5886	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$424.5886	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$424.5886	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days

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

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%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Michigan — 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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$424.5886	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$424.5886	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$449.8851	$449.891 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$449.8851	$449.891 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$424.5886	—	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
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	—	$453.2803	—	Prior authorization
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Indiana and Kentucky — 8 plans, 8 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 · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$431.3640	—	Prior authorization
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$431.3640	—	Prior authorization
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$431.3640	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Wisconsin — 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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$401.6500	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$401.6500	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$424.5886	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$424.5886	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$424.5886	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days

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

Missouri — 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%	$417.9200	—	Prior authorization
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$417.9200	—	Prior authorization
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$442.6562	—	Prior authorization
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$442.6562	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$479.6968	$479.701 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$479.6968	$479.701 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$442.6562	—	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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Louisiana — 8 plans, 8 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 · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$424.5886	—	Prior authorization
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$401.6500	—	Prior authorization
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$401.6500	—	Prior authorization
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$424.5886	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$424.5886	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$452.5953	$452.601 unit	Prior authorization Quantity limit 1 per 28 days

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

Colorado — 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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	—	$453.2803	—	Prior authorization
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Arizona — 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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	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
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	—	$453.2803	—	Prior authorization
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$453.2803	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days

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

Idaho and Utah — 8 plans, 8 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 · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$453.2803	—	Prior authorization
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$458.3000	—	Prior authorization
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$453.2803	—	Prior authorization
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$458.3000	—	Prior authorization
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$492.6513	$492.651 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$492.6513	$492.651 unit	Prior authorization Quantity limit 1 per 28 days

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

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%	$444.9712	—	Prior authorization
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$444.9712	—	Prior authorization
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$444.4646	—	Prior authorization
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$425.0293	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$453.3659	$453.371 unit	Prior authorization Quantity limit 1 per 28 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$425.0293	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$453.3659	$453.371 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$425.0293	—	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
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	38%	—	$459.3706	$459.371 unit	Prior authorization Quantity limit 1 per 28 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	—	$427.5999	—	Prior authorization
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$444.4646	—	Prior authorization
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$427.5999	—	Prior authorization
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$427.5999	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$459.3706	$459.371 unit	Prior authorization Quantity limit 1 per 28 days

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

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 · $0 with full Extra Help	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	—	$453.2803	—	Prior authorization
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$453.2803	—	Prior authorization
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$432.0828	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$469.8617	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$469.9402	$469.941 unit	Prior authorization Quantity limit 1 per 28 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$453.2803	—	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 · $0 with full Extra Help	4Non-Preferred Drug	25%	25%	$471.7303	$471.731 unit	Prior authorization Quantity limit 1 per 28 days

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

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 · $0 with full Extra Help	4Non-Preferred Drug	25%	25%	$471.7303	$471.731 unit	Prior authorization Quantity limit 1 per 28 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Maximum premiumMaximum deductiblePlanSort by

Showing 1 of 1 plan

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$471.7303	$471.731 unit	Prior authorization Quantity limit 1 per 28 days

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

Puerto Rico — 1 plan, 1 with restrictions

Maximum premiumMaximum deductiblePlanSort by

Showing 1 of 1 plan

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%	$455.2904	$455.291 unit	Prior authorization Quantity limit 1 per 28 days

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

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

Maximum premiumMaximum deductiblePlanSort by

Showing 1 of 1 plan

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$471.7303	$471.731 unit	Prior authorization Quantity limit 1 per 28 days

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

ELIGARD Kit

Medicare Advantage plans in your county

Coverage by region

Plan-by-plan detail