BUPRENORPHINE 7.5 ug/h Patch, Extended Release

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Pennsylvania and West Virginia	7 of 12	3–4	—	7 of 7 plans
Connecticut, Massachusetts, Rhode Island and Vermont	5 of 11	3–4	—	5 of 5 plans
South Carolina	5 of 11	3–4	—	5 of 5 plans
Indiana and Kentucky	5 of 10	3–4	—	5 of 5 plans
Wisconsin	5 of 10	3–4	—	5 of 5 plans
Louisiana	5 of 10	3–4	—	5 of 5 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	5 of 11	3–4	—	5 of 5 plans
Idaho and Utah	5 of 10	3–4	—	5 of 5 plans
Hawaii	5 of 8	3–4	—	5 of 5 plans
Maine and New Hampshire	4 of 9	3–4	—	4 of 4 plans
New York	4 of 10	3–4	—	4 of 4 plans
New Jersey	4 of 12	3–4	—	4 of 4 plans
Delaware, DC and Maryland	4 of 10	3–4	—	4 of 4 plans
Virginia	4 of 9	3–4	—	4 of 4 plans
North Carolina	4 of 12	3–4	—	4 of 4 plans
Georgia	4 of 10	3–4	—	4 of 4 plans
Florida	4 of 10	3–4	—	4 of 4 plans
Alabama and Tennessee	4 of 12	3–4	—	4 of 4 plans
Michigan	4 of 12	3–4	—	4 of 4 plans
Ohio	4 of 10	3–4	—	4 of 4 plans
Illinois	4 of 12	3–4	—	4 of 4 plans
Missouri	4 of 10	3–4	—	4 of 4 plans
Arkansas	4 of 12	3–4	—	4 of 4 plans
Mississippi	4 of 10	3–4	—	4 of 4 plans
Texas	4 of 12	3–4	—	4 of 4 plans
Oklahoma	4 of 11	3–4	—	4 of 4 plans
Kansas	4 of 12	3–4	—	4 of 4 plans
New Mexico	4 of 11	3–4	—	4 of 4 plans
Colorado	4 of 10	3–4	—	4 of 4 plans
Arizona	4 of 10	3–4	—	4 of 4 plans
Nevada	4 of 10	3–4	—	4 of 4 plans
Oregon and Washington	4 of 10	3–4	—	4 of 4 plans
California	4 of 12	3–4	—	4 of 4 plans
Alaska	4 of 9	3–4	—	4 of 4 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
Puerto Rico	1 of 3	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	1 of 1 plans

Pennsylvania and West Virginia — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$47.3883	$189.554 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$55.9502	$223.804 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$56.6544	$226.624 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$48.0168	$192.074 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$55.5541	$222.224 units	Prior authorization Quantity limit 4 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$59.4808	$237.924 units	Prior authorization Quantity limit 4 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$59.5755	$238.304 units	Prior authorization Quantity limit 4 per 28 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$47.3002	$189.204 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$62.6209	$250.484 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$51.2632	$205.054 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$62.8444	$251.384 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$62.4952	$249.984 units	Prior authorization Quantity limit 4 per 28 days

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

South Carolina — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.0299	$176.124 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$60.2363	$240.954 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$60.8549	$243.424 units	Prior authorization Quantity limit 4 per 28 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$56.8606	$227.444 units	Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$59.8883	$239.554 units	Prior authorization Quantity limit 4 per 28 days

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

Indiana and Kentucky — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$44.7464	$178.994 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$59.8546	$239.424 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$60.6060	$242.424 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$48.6847	$194.744 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$59.4320	$237.734 units	Prior authorization Quantity limit 4 per 28 days

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

Wisconsin — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$44.3606	$177.444 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$61.3960	$245.584 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$62.4089	$249.644 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$48.1395	$192.564 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$60.8263	$243.314 units	Prior authorization Quantity limit 4 per 28 days

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

Louisiana — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$44.8233	$179.294 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$68.2124	$272.854 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$68.9462	$275.784 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$52.7004	$210.804 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$67.7997	$271.204 units	Prior authorization Quantity limit 4 per 28 days

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$44.2548	$177.024 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$59.1952	$236.784 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$59.7612	$239.044 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$48.6380	$194.554 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$58.8768	$235.514 units	Prior authorization Quantity limit 4 per 28 days

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

Idaho and Utah — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$43.4579	$173.834 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$56.7628	$227.054 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$57.6707	$230.684 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$45.2664	$181.074 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$56.2520	$225.014 units	Prior authorization Quantity limit 4 per 28 days

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

Hawaii — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$46.9877	$187.954 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$59.6160	$238.464 units	Prior authorization Quantity limit 4 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$57.0611	$228.244 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$59.6160	$238.464 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$59.6160	$238.464 units	Prior authorization Quantity limit 4 per 28 days

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

Maine and New Hampshire — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$43.9728	$175.894 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$61.3945	$245.584 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$62.5987	$250.394 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$60.7171	$242.874 units	Prior authorization Quantity limit 4 per 28 days

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

New York — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$44.4439	$177.784 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$60.5758	$242.304 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$60.8839	$243.544 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$60.4026	$241.614 units	Prior authorization Quantity limit 4 per 28 days

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

New Jersey — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$49.2138	$196.864 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$64.6178	$258.474 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$64.8003	$259.204 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$64.5151	$258.064 units	Prior authorization Quantity limit 4 per 28 days

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

Delaware, DC and Maryland — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$43.9058	$175.624 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$62.0540	$248.224 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$62.5483	$250.194 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$61.7759	$247.104 units	Prior authorization Quantity limit 4 per 28 days

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

Virginia — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$45.0942	$180.384 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$60.7526	$243.014 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$61.7897	$247.164 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$60.1692	$240.684 units	Prior authorization Quantity limit 4 per 28 days

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

North Carolina — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.3581	$177.434 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$62.2424	$248.974 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$63.0970	$252.394 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$61.7616	$247.054 units	Prior authorization Quantity limit 4 per 28 days

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

Georgia — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$43.9609	$175.844 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$60.3458	$241.384 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$60.9062	$243.624 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$60.0306	$240.124 units	Prior authorization Quantity limit 4 per 28 days

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

Florida — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.2630	$177.054 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$65.2184	$260.874 units	Prior authorization Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$64.7070	$258.834 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$64.4193	$257.684 units	Prior authorization Quantity limit 4 per 28 days

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

Alabama and Tennessee — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.1415	$176.574 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$62.1651	$248.664 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$62.7817	$251.134 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$61.8183	$247.274 units	Prior authorization Quantity limit 4 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 — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$43.6651	$174.664 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$60.5872	$242.354 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$60.8379	$243.354 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$60.4462	$241.784 units	Prior authorization Quantity limit 4 per 28 days

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

Ohio — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.3320	$177.334 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$59.1860	$236.744 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$59.7603	$239.044 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$58.8631	$235.454 units	Prior authorization Quantity limit 4 per 28 days

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

Illinois — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$45.1904	$180.764 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$64.2453	$256.984 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$65.2293	$260.924 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$63.6918	$254.774 units	Prior authorization Quantity limit 4 per 28 days

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

Missouri — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.3777	$177.514 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$60.2522	$241.014 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$60.9421	$243.774 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$59.8641	$239.464 units	Prior authorization Quantity limit 4 per 28 days

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

Arkansas — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$43.1873	$172.754 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$59.0314	$236.134 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$59.8550	$239.424 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$58.5681	$234.274 units	Prior authorization Quantity limit 4 per 28 days

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

Mississippi — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$44.4024	$177.614 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$59.4358	$237.744 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$60.8687	$243.474 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$58.6299	$234.524 units	Prior authorization Quantity limit 4 per 28 days

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

Texas — 4 plans, 4 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 · $130.00 deductible	3Preferred Brand	18%	18%	$44.3176	$177.274 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$63.8458	$255.384 units	Prior authorization Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$63.0206	$252.084 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$62.5564	$250.234 units	Prior authorization Quantity limit 4 per 28 days

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

Oklahoma — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$43.3591	$173.444 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$62.3786	$249.514 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$63.2025	$252.814 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$61.9151	$247.664 units	Prior authorization Quantity limit 4 per 28 days

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

Kansas — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$44.0052	$176.024 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$60.1895	$240.764 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$61.1600	$244.644 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$59.6436	$238.574 units	Prior authorization Quantity limit 4 per 28 days

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

New Mexico — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$48.5384	$194.154 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$67.1314	$268.534 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$68.6535	$274.614 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$66.2752	$265.104 units	Prior authorization Quantity limit 4 per 28 days

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

Colorado — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$44.3114	$177.254 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$59.2980	$237.194 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$60.2883	$241.154 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$58.7409	$234.964 units	Prior authorization Quantity limit 4 per 28 days

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

Arizona — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$46.0777	$184.314 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$66.0249	$264.104 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$66.7322	$266.934 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$65.6271	$262.514 units	Prior authorization Quantity limit 4 per 28 days

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

Nevada — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$44.7127	$178.854 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$64.3827	$257.534 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$64.8847	$259.544 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$64.1003	$256.404 units	Prior authorization Quantity limit 4 per 28 days

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

Oregon and Washington — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$44.5795	$178.324 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$58.6416	$234.574 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$59.4944	$237.984 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$58.1619	$232.654 units	Prior authorization Quantity limit 4 per 28 days

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

California — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$44.7833	$179.134 units	Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$62.4044	$249.624 units	Prior authorization Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$62.0494	$248.204 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$61.8497	$247.404 units	Prior authorization Quantity limit 4 per 28 days

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

Alaska — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$43.3804	$173.524 units	Quantity limit 4 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$53.0179	$212.074 units	Prior authorization Quantity limit 4 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$53.0179	$212.074 units	Prior authorization Quantity limit 4 per 28 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$53.0179	$212.074 units	Prior authorization Quantity limit 4 per 28 days

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$51.8715	$207.494 units	Quantity limit 4 per 28 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$51.8715	$207.494 units	Quantity limit 4 per 28 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$51.8715	$207.494 units	Quantity limit 4 per 28 days

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

Puerto Rico — 1 plan, 1 with restrictions

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	3Preferred Brand	25%	25%	$80.2556	$321.024 units	Quantity limit 4 per 28 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$51.8715	$207.494 units	Quantity limit 4 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.

Coverage by region

Plan-by-plan detail