ARISTADA 1064 mg/3.9mL Injection, Suspension, Extended Release (Aripiprazole Lauroxil) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Connecticut, Massachusetts, Rhode Island and Vermont	10 of 11	4–5	—	8 of 10 plans
Pennsylvania and West Virginia	10 of 12	4–5	—	8 of 10 plans
Michigan	10 of 12	4–5	—	8 of 10 plans
Arkansas	10 of 12	4–5	—	8 of 10 plans
Kansas	10 of 12	4–5	—	8 of 10 plans
New Jersey	9 of 12	4–5	—	7 of 9 plans
North Carolina	9 of 12	4–5	—	7 of 9 plans
South Carolina	9 of 11	4–5	—	6 of 9 plans
Florida	9 of 10	4–5	—	7 of 9 plans
Alabama and Tennessee	9 of 12	4–5	—	7 of 9 plans
Illinois	9 of 12	4–5	—	7 of 9 plans
Texas	9 of 12	4–5	—	7 of 9 plans
New Mexico	9 of 11	4–5	—	7 of 9 plans
Maine and New Hampshire	8 of 9	4–5	—	6 of 8 plans
New York	8 of 10	4–5	—	6 of 8 plans
Delaware, DC and Maryland	8 of 10	4–5	—	6 of 8 plans
Virginia	8 of 9	4–5	—	6 of 8 plans
Georgia	8 of 10	4–5	—	6 of 8 plans
Ohio	8 of 10	4–5	—	6 of 8 plans
Indiana and Kentucky	8 of 10	4–5	—	6 of 8 plans
Wisconsin	8 of 10	4–5	—	6 of 8 plans
Missouri	8 of 10	4–5	—	6 of 8 plans
Mississippi	8 of 10	4–5	—	6 of 8 plans
Louisiana	8 of 10	4–5	—	6 of 8 plans
Oklahoma	8 of 11	4–5	—	6 of 8 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	8 of 11	4–5	—	6 of 8 plans
Colorado	8 of 10	4–5	—	6 of 8 plans
Arizona	8 of 10	4–5	—	6 of 8 plans
Nevada	8 of 10	4–5	—	6 of 8 plans
Oregon and Washington	8 of 10	4–5	—	6 of 8 plans
Idaho and Utah	8 of 10	4–5	—	6 of 8 plans
California	8 of 12	4–5	—	6 of 8 plans
Hawaii	8 of 8	4–5	—	6 of 8 plans
Alaska	8 of 9	4–5	—	6 of 8 plans
American Samoa	1 of 1	5	—	none
Guam	1 of 1	5	—	none
Northern Mariana Islands	1 of 1	5	—	none
Puerto Rico	1 of 3	5	—	none
U.S. Virgin Islands	1 of 1	5	—	none

Connecticut, Massachusetts, Rhode Island and Vermont — 10 plans, 8 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	4Non-Preferred Drug	32%	—	$991.9866	$1,983.972 units	Quantity limit 3.9 per 56 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$996.3816	$1,992.762 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$991.9866	$1,983.972 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$991.9866	$1,983.972 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$987.2745	$1,974.552 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$987.2745	$1,974.552 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1079.9472	—	None
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1079.9472	—	None
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$996.3816	$1,992.762 units	Quantity limit 3.9 per 56 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, 8 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	4Non-Preferred Drug	33%	—	$985.3535	$1,970.712 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$985.3535	$1,970.712 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$985.3535	$1,970.712 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$958.3898	$1,916.782 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$958.3898	$1,916.782 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1061.9349	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1061.9349	—	None
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$970.3287	$3,881.314 units	Quantity limit 3.9 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$969.4632	$3,877.854 units	Quantity limit 3.9 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 — 10 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	4Non-Preferred Drug	33%	—	$985.8842	$1,971.772 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$985.8842	$1,971.772 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$985.8842	$1,971.772 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$968.5376	$1,937.082 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$968.5376	$1,937.082 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1079.2290	—	None
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.8172	$2,053.632 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1079.2290	—	None
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1014.2566	$2,028.512 units	Step therapy Quantity limit 3.9 per 56 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1014.2566	$2,028.512 units	Step therapy Quantity limit 3.9 per 56 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, 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	4Non-Preferred Drug	34%	—	$991.2391	$1,982.482 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$991.2391	$1,982.482 units	Quantity limit 3.9 per 56 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$1013.5315	$2,027.062 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$991.2391	$1,982.482 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$952.1904	$1,904.382 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$952.1904	$1,904.382 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1073.8932	—	None
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.9402	$2,053.882 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1073.8932	—	None
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1013.5315	$2,027.062 units	Quantity limit 3.9 per 56 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 — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$982.7494	$1,965.502 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$982.7494	$1,965.502 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$982.7494	$1,965.502 units	Quantity limit 3.9 per 56 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1059.3539	$2,118.712 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$981.7172	$1,963.432 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$981.7172	$1,963.432 units	Quantity limit 3.9 per 56 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1058.8200	$2,117.642 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1032.9784	$2,065.962 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1091.2966	—	None
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1091.2966	—	None

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 — 9 plans, 7 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	4Non-Preferred Drug	32%	—	$986.7559	$1,973.512 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$986.7559	$1,973.512 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$986.7559	$1,973.512 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$939.5974	$1,879.192 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$939.5974	$1,879.192 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1072.3370	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1072.3370	—	None
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$1043.8484	$2,087.702 units	Quantity limit 3.9 per 56 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 — 9 plans, 7 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	4Non-Preferred Drug	32%	—	$994.3726	$1,988.752 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$994.3726	$1,988.752 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$994.3726	$1,988.752 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$954.6893	$1,909.382 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$954.6893	$1,909.382 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1076.6196	—	None
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1076.6196	—	None
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1046.4817	$2,092.962 units	Quantity limit 3.9 per 56 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 — 9 plans, 6 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	4Non-Preferred Drug	30%	—	$986.9764	$1,973.952 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$986.9764	$1,973.952 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$986.9764	$1,973.952 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$947.7076	$1,895.422 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$947.7076	$1,895.422 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1045.4031	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1045.4031	—	None
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1004.7833	—	None

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 — 9 plans, 7 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	4Non-Preferred Drug	33%	—	$992.1438	$1,984.292 units	Quantity limit 3.9 per 56 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$992.1438	$1,984.292 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$992.1438	$1,984.292 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$966.1257	$1,932.252 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$966.1257	$1,932.252 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1074.3926	—	None
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1074.3926	—	None
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1034.2878	$2,068.582 units	Quantity limit 3.9 per 56 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 — 9 plans, 7 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	4Non-Preferred Drug	34%	—	$987.4515	$1,974.902 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$987.4515	$1,974.902 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$987.4515	$1,974.902 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$965.0575	$1,930.122 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$965.0575	$1,930.122 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1077.0207	—	None
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1077.0207	—	None
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$1025.3542	$2,050.712 units	Quantity limit 3.9 per 56 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 — 9 plans, 7 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	4Non-Preferred Drug	34%	—	$996.8757	$1,993.752 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$996.8757	$1,993.752 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$996.8757	$1,993.752 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$967.9399	$1,935.882 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$967.9399	$1,935.882 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1089.8914	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1089.8914	—	None
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1060.3977	$2,120.802 units	Quantity limit 3.9 per 56 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 — 9 plans, 7 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	4Non-Preferred Drug	34%	—	$991.0716	$1,982.142 units	Quantity limit 3.9 per 56 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$991.0716	$1,982.142 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$991.0716	$1,982.142 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$963.4429	$1,926.892 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$963.4429	$1,926.892 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1080.4202	—	None
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1080.4202	—	None
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1044.8536	$2,089.712 units	Quantity limit 3.9 per 56 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 — 9 plans, 7 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	4Non-Preferred Drug	32%	—	$993.4978	$1,987.002 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$993.4978	$1,987.002 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$993.4978	$1,987.002 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1017.7334	$2,035.472 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1017.7334	$2,035.472 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1088.3858	—	None
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1088.3858	—	None
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1043.7853	$2,087.572 units	Quantity limit 3.9 per 56 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, 6 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	4Non-Preferred Drug	33%	—	$1001.8610	$2,003.722 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$1001.8610	$2,003.722 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1001.8610	$2,003.722 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$967.4115	$1,934.822 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$967.4115	$1,934.822 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1115.1839	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.8101	$2,053.622 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1115.1839	—	None

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, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$983.1593	$1,966.322 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$983.1593	$1,966.322 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$983.1593	$1,966.322 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$950.6270	$1,901.252 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$950.6270	$1,901.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1057.2925	—	None
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1057.2925	—	None

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, 6 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	4Non-Preferred Drug	33%	—	$984.4272	$1,968.852 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$984.4272	$1,968.852 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$984.4272	$1,968.852 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$977.2344	$1,954.472 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$977.2344	$1,954.472 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1076.1814	—	None
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1076.1814	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 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 — 8 plans, 6 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	4Non-Preferred Drug	33%	—	$993.0321	$1,986.062 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$993.0321	$1,986.062 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$993.0321	$1,986.062 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$981.1732	$1,962.352 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$981.1732	$1,962.352 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1090.5660	—	None
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1090.5660	—	None

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, 6 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	4Non-Preferred Drug	34%	—	$988.8208	$1,977.642 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$988.8208	$1,977.642 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$988.8208	$1,977.642 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$970.2155	$1,940.432 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$970.2155	$1,940.432 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1080.9414	—	None
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.7250	$2,053.452 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1080.9414	—	None

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, 6 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	4Non-Preferred Drug	31%	—	$987.8908	$1,975.782 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$987.8908	$1,975.782 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$987.8908	$1,975.782 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$997.3912	$1,994.782 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$997.3912	$1,994.782 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1103.3688	—	None
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6954	$2,053.392 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1103.3688	—	None

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, 6 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	4Non-Preferred Drug	33%	—	$983.6738	$1,967.352 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$983.6738	$1,967.352 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$983.6738	$1,967.352 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1011.1819	$2,022.362 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1011.1819	$2,022.362 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1113.8383	—	None
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1113.8383	—	None

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, 6 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	4Non-Preferred Drug	32%	—	$986.4636	$1,972.932 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$986.4636	$1,972.932 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$986.4636	$1,972.932 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$978.2444	$1,956.492 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$978.2444	$1,956.492 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1091.5609	—	None
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1091.5609	—	None

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, 6 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	4Non-Preferred Drug	35%	—	$986.5005	$1,973.002 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$986.5005	$1,973.002 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$986.5005	$1,973.002 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$949.0610	$1,898.122 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$949.0610	$1,898.122 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1063.3957	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1027.8246	$2,055.652 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1063.3957	—	None

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, 6 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	4Non-Preferred Drug	35%	—	$982.9936	$1,965.992 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$982.9936	$1,965.992 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$982.9936	$1,965.992 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$984.7814	$1,969.562 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$984.7814	$1,969.562 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1076.3365	—	None
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1076.3365	—	None

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, 6 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	4Non-Preferred Drug	32%	—	$987.8524	$1,975.702 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$987.8524	$1,975.702 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$987.8524	$1,975.702 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$948.9383	$1,897.882 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$948.9383	$1,897.882 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1076.0853	—	None
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1076.0853	—	None

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 — 8 plans, 6 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	4Non-Preferred Drug	29%	—	$993.3259	$1,986.652 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$993.3259	$1,986.652 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$993.3259	$1,986.652 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$989.0131	$1,978.032 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$989.0131	$1,978.032 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1053.6291	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1053.6291	—	None
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1049.5497	$2,099.102 units	Quantity limit 3.9 per 56 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 — 8 plans, 6 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	4Non-Preferred Drug	34%	—	$992.3254	$1,984.652 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$992.3254	$1,984.652 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$992.3254	$1,984.652 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1071.3958	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$985.6498	$1,971.302 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$985.6498	$1,971.302 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1028.5041	$2,057.012 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1071.3958	—	None

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, 6 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	4Non-Preferred Drug	31%	—	$981.7983	$1,963.602 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$981.7983	$1,963.602 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$981.7983	$1,963.602 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$988.8956	$1,977.792 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$988.8956	$1,977.792 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1084.1827	—	None
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1084.1827	—	None

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, 6 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	4Non-Preferred Drug	30%	—	$984.0425	$1,968.092 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$984.0425	$1,968.092 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$984.0425	$1,968.092 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1048.5950	$2,097.192 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1048.5950	$2,097.192 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1120.5964	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1120.5964	—	None

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, 6 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	4Non-Preferred Drug	32%	—	$998.7261	$1,997.452 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$998.7261	$1,997.452 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$998.7261	$1,997.452 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1005.0746	$2,010.152 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1005.0746	$2,010.152 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1067.4867	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1067.4867	—	None

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, 6 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	4Non-Preferred Drug	33%	—	$996.8772	$1,993.752 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$996.8772	$1,993.752 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$996.8772	$1,993.752 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1007.5727	$2,015.152 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1007.5727	$2,015.152 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1099.8613	—	None
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1028.4171	$2,056.832 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1099.8613	—	None

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, 6 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	4Non-Preferred Drug	33%	—	$984.7798	$1,969.562 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$984.7798	$1,969.562 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$984.7798	$1,969.562 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$950.1747	$1,900.352 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$950.1747	$1,900.352 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1027.9999	$2,056.002 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1078.2878	—	None
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1078.2878	—	None

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, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$983.5222	$1,967.042 units	Quantity limit 3.9 per 56 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$983.5222	$1,967.042 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$983.5222	$1,967.042 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$961.0900	$1,922.182 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$961.0900	$1,922.182 units	Quantity limit 3.9 per 56 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1055.0001	—	None
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1055.0001	—	None

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, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$1001.0611	$2,002.122 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$1001.0611	$2,002.122 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1001.0611	$2,002.122 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1075.0552	—	None
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1034.2753	$2,068.552 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$973.3228	$1,946.652 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$973.3228	$1,946.652 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1075.0552	—	None

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, 6 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	4Non-Preferred Drug	28%	—	$991.8234	$1,983.652 units	Quantity limit 3.9 per 56 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$991.8234	$1,983.652 units	Quantity limit 3.9 per 56 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$991.8234	$1,983.652 units	Quantity limit 3.9 per 56 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$971.6043	$1,943.212 units	Quantity limit 3.9 per 56 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$971.6043	$1,943.212 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1110.2843	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1026.6232	$2,053.252 units	Quantity limit 3.9 per 56 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1110.2843	—	None

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$1089.6013	—	None

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$1089.6013	—	None

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$1089.6013	—	None

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

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	5Specialty Tier	25%	25%	$1089.6013	—	None

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$1089.6013	—	None

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.

ARISTADA 1064 mg/3.9mL Injection, Suspension, Extended Release

Coverage by region

Plan-by-plan detail