ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	3–4	$45.00	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	2–4	$5.00	12 of 12 plans
North Carolina	12 of 12	3–4	$45.00	12 of 12 plans
Alabama and Tennessee	12 of 12	3–4	$45.00	12 of 12 plans
Michigan	12 of 12	3–4	$45.00	12 of 12 plans
Illinois	12 of 12	3–4	$45.00	12 of 12 plans
Arkansas	12 of 12	3–4	$45.00	12 of 12 plans
Texas	12 of 12	3–4	$45.00	12 of 12 plans
Kansas	12 of 12	3–4	$45.00	12 of 12 plans
California	12 of 12	2–4	$7.00	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	2–4	$10.00	11 of 11 plans
South Carolina	11 of 11	3–4	$45.00	10 of 11 plans
Oklahoma	11 of 11	3–4	$45.00	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	2–4	$10.00	11 of 11 plans
New Mexico	11 of 11	3–4	$45.00	11 of 11 plans
New York	10 of 10	3–4	$45.00	10 of 10 plans
Delaware, DC and Maryland	10 of 10	3–4	$45.00	10 of 10 plans
Georgia	10 of 10	3–4	$45.00	10 of 10 plans
Florida	10 of 10	3–4	$45.00	10 of 10 plans
Ohio	10 of 10	3–4	$45.00	10 of 10 plans
Indiana and Kentucky	10 of 10	2–4	$10.00	10 of 10 plans
Wisconsin	10 of 10	2–4	$10.00	10 of 10 plans
Missouri	10 of 10	3–4	$45.00	10 of 10 plans
Mississippi	10 of 10	3–4	$45.00	10 of 10 plans
Louisiana	10 of 10	2–4	$10.00	10 of 10 plans
Colorado	10 of 10	3–4	$45.00	10 of 10 plans
Arizona	10 of 10	3–4	$45.00	10 of 10 plans
Nevada	10 of 10	3–4	$45.00	10 of 10 plans
Oregon and Washington	10 of 10	3–4	$45.00	10 of 10 plans
Idaho and Utah	10 of 10	2–4	$10.00	10 of 10 plans
Maine and New Hampshire	9 of 9	3–4	$45.00	9 of 9 plans
Virginia	9 of 9	3–4	$45.00	9 of 9 plans
Alaska	9 of 9	3–4	$45.00	9 of 9 plans
Hawaii	8 of 8	2–4	$10.00	8 of 8 plans
Puerto Rico	3 of 3	3	—	3 of 3 plans
American Samoa	1 of 1	3	—	1 of 1 plans
Guam	1 of 1	3	—	1 of 1 plans
Northern Mariana Islands	1 of 1	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	1 of 1 plans

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7236	$19.5427 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.7248	$19.5727 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.4983	$22.4245 units	Quantity limit 45 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.6424	$44.3427 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4914	$13.2727 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4983	$22.4245 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7230	$19.5227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4357	$19.6145 units	Quantity limit 45 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$1.6424	$44.3427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5004	$13.5127 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4855	$13.1127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.3692	$16.6145 units	Quantity limit 45 per 30 days

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

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4871	$13.1527 units	Quantity limit 27 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.5107	$2,553.505000 units	Prior authorization Quantity limit 5167 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.4981	$2,490.505000 units	Prior authorization Quantity limit 5167 per 31 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.6972	$18.8227 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.6985	$18.8627 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4980	$22.4145 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4980	$22.4145 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4457	$20.0645 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.6964	$18.8027 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4987	$13.4627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4916	$13.2727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.4070	$18.3145 units	Quantity limit 45 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7424	$20.0427 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7608	$20.5427 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5214	$23.4645 units	Quantity limit 45 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$1.6905	$45.6427 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4829	$13.0427 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5214	$23.4645 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7320	$19.7627 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4311	$19.4045 units	Quantity limit 45 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$1.6905	$45.6427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5206	$14.0627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5122	$13.8327 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3556	$16.0045 units	Quantity limit 45 per 30 days

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

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7430	$20.0627 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7760	$20.9527 units	Quantity limit 27 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$1.6724	$45.1527 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4928	$22.1845 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.4928	$22.1845 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4920	$13.2827 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7243	$19.5627 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4342	$19.5445 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4936	$13.3327 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4926	$13.3027 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3689	$16.6045 units	Quantity limit 45 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$1.6724	$45.1527 units	Quantity limit 27 per 30 days

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

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4410	$19.8445 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8002	$21.6127 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8016	$21.6427 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4410	$19.8445 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4899	$13.2327 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4400	$19.8045 units	Quantity limit 45 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4643	$2,321.505000 units	Quantity limit 5167 per 31 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7994	$21.5827 units	Quantity limit 27 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$0.4643	$2,321.505000 units	Quantity limit 5167 per 31 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4438	$11.9827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4472	$12.0727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3939	$17.7345 units	Quantity limit 45 per 30 days

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

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8140	$21.9827 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8220	$22.1927 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4790	$21.5545 units	Quantity limit 45 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$1.6682	$45.0427 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4803	$12.9727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4328	$19.4845 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4790	$21.5545 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8095	$21.8627 units	Quantity limit 27 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.6435	$44.3727 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4886	$13.1927 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4902	$13.2427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.3707	$16.6845 units	Quantity limit 45 per 30 days

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

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4712	$21.2045 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.6646	$17.9427 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7122	$19.2327 units	Quantity limit 27 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2957	$7.9827 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4712	$21.2045 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4717	$12.7427 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.6376	$17.2227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4352	$19.5845 units	Quantity limit 45 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.2957	$7.9827 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4658	$12.5827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4659	$12.5827 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3744	$16.8545 units	Quantity limit 45 per 30 days

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

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7918	$21.3827 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7840	$21.1727 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4699	$21.1545 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4853	$13.1027 units	Quantity limit 27 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$1.6582	$44.7727 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4699	$21.1545 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4324	$19.4645 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7795	$21.0527 units	Quantity limit 27 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.6326	$44.0827 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4674	$12.6227 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4727	$12.7627 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.3742	$16.8445 units	Quantity limit 45 per 30 days

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

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.6727	$45.1627 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.5001	$22.5045 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.6947	$18.7627 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7278	$19.6527 units	Quantity limit 27 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$1.6727	$45.1627 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4921	$13.2927 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.6760	$18.2527 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4328	$19.4845 units	Quantity limit 45 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.6734	$45.1827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4966	$13.4127 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4946	$13.3527 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.3680	$16.5645 units	Quantity limit 45 per 30 days

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

California — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	2Generic	$7.00	$17.50	$0.5045	$9.0818 units	Quantity limit 18 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.5045	$9.0818 units	Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4856	$21.8545 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4856	$21.8545 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4746	$12.8127 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.7501	$20.2527 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7461	$20.1427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4338	$19.5245 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7438	$20.0827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4869	$13.1527 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4762	$12.8627 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.3716	$16.7245 units	Quantity limit 45 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.

Connecticut, Massachusetts, Rhode Island and Vermont — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4927	$13.3027 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7984	$21.5627 units	Quantity limit 27 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2957	$7.9827 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.7992	$21.5827 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7980	$21.5527 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4952	$22.2845 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4351	$19.5845 units	Quantity limit 45 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$0.2957	$7.9827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4986	$13.4627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4891	$13.2127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3690	$16.6145 units	Quantity limit 45 per 30 days

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

South Carolina — 11 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7239	$19.5527 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.7290	$19.6827 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4860	$21.8745 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4910	$13.2627 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4363	$19.6345 units	Quantity limit 45 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4380	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7210	$19.4727 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4860	$21.8745 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4875	$13.1627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4756	$12.8427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.3720	$16.7445 units	Quantity limit 45 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.

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$1.6856	$45.5127 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8525	$23.0227 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8636	$23.3227 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4883	$21.9745 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8461	$22.8427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4356	$19.6045 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4883	$21.9745 units	Quantity limit 45 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.6719	$45.1427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4915	$13.2727 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4893	$13.2127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.3705	$16.6745 units	Quantity limit 45 per 30 days

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4821	$13.0227 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7330	$19.7927 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7424	$20.0427 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3952	$17.7845 units	Quantity limit 45 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$1.6762	$45.2627 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7277	$19.6527 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.3952	$17.7845 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4410	$19.8445 units	Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4079	$18.3645 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4458	$12.0427 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4503	$12.1627 units	Quantity limit 27 per 30 days

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

New Mexico — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.5233	$23.5545 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7738	$20.8927 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8061	$21.7627 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7556	$20.4027 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4323	$19.4545 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4743	$12.8127 units	Quantity limit 27 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.7322	$46.7727 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5202	$14.0527 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5219	$14.0927 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$0.3673	$16.5345 units	Quantity limit 45 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.6805	$45.3727 units	Quantity limit 27 per 30 days

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

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4545	$20.4545 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4545	$20.4545 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4913	$13.2727 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7203	$19.4527 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$0.7271	$19.6327 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4411	$19.8545 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7164	$19.3427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4586	$12.3827 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4507	$12.1727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.3904	$17.5745 units	Quantity limit 45 per 30 days

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

Delaware, DC and Maryland — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8052	$21.7427 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8130	$21.9527 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.4750	$21.3845 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4750	$21.3845 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4357	$19.6145 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4830	$13.0427 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8008	$21.6227 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4793	$12.9427 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4748	$12.8227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.3762	$16.9345 units	Quantity limit 45 per 30 days

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

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8451	$22.8227 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8607	$23.2427 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4953	$22.2945 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4901	$13.2327 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8363	$22.5827 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4343	$19.5445 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4953	$22.2945 units	Quantity limit 45 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4978	$13.4427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4991	$13.4827 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3665	$16.4945 units	Quantity limit 45 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.

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8052	$21.7427 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8004	$21.6127 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4744	$12.8127 units	Quantity limit 27 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$1.7046	$46.0227 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7976	$21.5427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4383	$19.7245 units	Quantity limit 45 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4616	$12.4627 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4672	$12.6127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3799	$17.1045 units	Quantity limit 45 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$1.7046	$46.0227 units	Quantity limit 27 per 30 days

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

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7309	$19.7327 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7439	$20.0927 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5075	$22.8445 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4878	$13.1727 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5075	$22.8445 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7235	$19.5327 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4330	$19.4845 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5052	$13.6427 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5019	$13.5527 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.3652	$16.4345 units	Quantity limit 45 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.

Indiana and Kentucky — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4868	$13.1427 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7912	$21.3627 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7942	$21.4427 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4920	$22.1445 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4920	$22.1445 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7895	$21.3227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4335	$19.5145 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4949	$13.3627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4890	$13.2027 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$0.3644	$16.4045 units	Quantity limit 45 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.

Wisconsin — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4861	$13.1227 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.5200	$23.4045 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8469	$22.8727 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8519	$23.0027 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.5200	$23.4045 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8440	$22.7927 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4317	$19.4345 units	Quantity limit 45 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.5157	$13.9227 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5240	$14.1527 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3549	$15.9745 units	Quantity limit 45 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.

Missouri — 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)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7781	$21.0127 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7936	$21.4327 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4512	$20.3045 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4512	$20.3045 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4818	$13.0127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4397	$19.7945 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7693	$20.7727 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4778	$12.9027 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4843	$13.0827 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.3862	$17.3845 units	Quantity limit 45 per 30 days

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

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7323	$19.7727 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7489	$20.2227 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4328	$19.4845 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4328	$19.4845 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7228	$19.5227 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4898	$13.2227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4417	$19.8845 units	Quantity limit 45 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4348	$11.7427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4359	$11.7727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$0.3943	$17.7445 units	Quantity limit 45 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.

Louisiana — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4877	$13.1727 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8384	$22.6427 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8562	$23.1227 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4520	$20.3445 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4520	$20.3445 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8284	$22.3727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4339	$19.5345 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4536	$12.2527 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4516	$12.1927 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$0.3652	$16.4345 units	Quantity limit 45 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.

Colorado — 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	3Preferred Brand	25%	20%	$0.7993	$21.5827 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8201	$22.1427 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4807	$21.6345 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4807	$21.6345 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4948	$13.3627 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7875	$21.2627 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4346	$19.5645 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4818	$13.0127 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4796	$12.9527 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.3699	$16.6545 units	Quantity limit 45 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.

Arizona — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4752	$21.3845 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$0.7794	$21.0427 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7946	$21.4527 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4752	$21.3845 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4825	$13.0327 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4417	$19.8845 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7708	$20.8127 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.4733	$12.7827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4759	$12.8527 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4009	$18.0445 units	Quantity limit 45 per 30 days

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

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8712	$23.5227 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.8726	$23.5627 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4640	$20.8845 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4640	$20.8845 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4929	$13.3127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4404	$19.8245 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8703	$23.5027 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4697	$12.6827 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4697	$12.6827 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3868	$17.4145 units	Quantity limit 45 per 30 days

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

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	24%	$0.4726	$21.2745 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7967	$21.5127 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8034	$21.6927 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.4726	$21.2745 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4339	$11.7227 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7929	$21.4127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4345	$19.5545 units	Quantity limit 45 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4752	$12.8327 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4757	$12.8427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.3779	$17.0145 units	Quantity limit 45 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.

Idaho and Utah — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4920	$13.2827 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.6825	$18.4327 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.6894	$18.6127 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4163	$18.7345 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.6786	$18.3227 units	Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.4163	$18.7345 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4388	$19.7545 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4150	$11.2127 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4147	$11.2027 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4005	$18.0245 units	Quantity limit 45 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.

Maine and New Hampshire — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.3953	$17.7945 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.6818	$18.4127 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.6878	$18.5727 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4868	$13.1427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4505	$20.2745 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.6784	$18.3227 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3933	$10.6227 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3958	$10.6927 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4253	$19.1445 units	Quantity limit 45 per 30 days

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

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.8301	$22.4127 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.8413	$22.7227 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4860	$13.1227 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.8238	$22.2427 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4316	$19.4245 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5153	$23.1945 units	Quantity limit 45 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5117	$13.8227 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5181	$13.9927 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.3557	$16.0145 units	Quantity limit 45 per 30 days

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

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.3081	$13.8645 units	Quantity limit 45 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	19%	$0.6240	$16.8527 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.6240	$16.8527 units	Quantity limit 27 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4929	$13.3127 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4517	$20.3345 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.6240	$16.8527 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3081	$8.3227 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3081	$8.3227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4517	$20.3345 units	Quantity limit 45 per 30 days

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

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4929	$13.3127 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$0.7140	$19.2827 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7140	$19.2827 units	Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7140	$19.2827 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4331	$19.4945 units	Quantity limit 45 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.3595	$16.1845 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5317	$14.3627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.5124	$13.8327 units	Quantity limit 27 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.

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3764	$16.9445 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.3764	$16.9445 units	Quantity limit 45 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4599	$20.7045 units	Quantity limit 45 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.

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4512	$20.3045 units	Quantity limit 45 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.

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4512	$20.3045 units	Quantity limit 45 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.

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4512	$20.3045 units	Quantity limit 45 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.

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4512	$20.3045 units	Quantity limit 45 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.

Coverage by region

Plan-by-plan detail