EVEROLIMUS 2.5 mg Tablet

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

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$477.7000	$1,433.103 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$477.7000	$1,433.103 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$63.0153	$189.053 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$63.0153	$189.053 units	Prior authorization Quantity limit 3 per 30 days

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

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$316.0500	$948.153 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$316.0500	$948.153 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.1770	—	Prior authorization
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.7273	$692.183 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.8126	$692.443 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.1848	—	Prior authorization
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$276.1379	$8,284.1430 units	Prior authorization Quantity limit 31 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$276.7706	$8,303.1230 units	Prior authorization Quantity limit 31 per 31 days

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

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$287.9571	$863.873 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$287.9571	$863.873 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3756	—	Prior authorization
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$223.2770	$669.833 units	Prior authorization Quantity limit 3 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$83.7644	$251.293 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$223.3100	$669.933 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$34.4422	—	Prior authorization
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$83.7644	$251.293 units	Prior authorization Quantity limit 3 per 30 days

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

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$325.2515	$975.753 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$325.2515	$975.753 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3500	—	Prior authorization
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$18.1755	$54.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.4236	$694.273 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.4931	$694.483 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$35.2066	—	Prior authorization
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$18.1755	$54.533 units	Prior authorization Quantity limit 3 per 30 days

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

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$254.4496	$763.353 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$254.4496	$763.353 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$31.1962	—	Prior authorization
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$31.1962	—	Prior authorization

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

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$385.6647	$1,156.993 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$385.6647	$1,156.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.2915	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6411	$694.923 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$50.0595	$150.183 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$36.9545	—	Prior authorization
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$32.9543	$98.863 units	Prior authorization Quantity limit 3 per 30 days

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

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.4703	$1,015.413 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.2625	$1,014.793 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.6359	$712.913 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$272.6197	$817.863 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.8330	$713.503 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$272.6197	$817.863 units	Prior authorization Quantity limit 3 per 30 days

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

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$267.9955	$803.993 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$267.9955	$803.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.8322	$692.503 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3245	—	Prior authorization
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$25.8955	$77.693 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.9180	$692.753 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.3245	—	Prior authorization
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$24.4444	$73.333 units	Prior authorization Quantity limit 3 per 30 days

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

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$82.4746	$247.423 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$82.4746	$247.423 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$228.6020	$685.813 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$238.4305	$715.293 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$238.4305	$715.293 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$82.4746	$247.423 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

California — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.9267	$692.783 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$370.7642	$1,112.293 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$370.7642	$1,112.293 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.9001	$692.703 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.8771	—	Prior authorization
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$37.2563	—	Prior authorization
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$66.0856	$1,982.5730 units	Prior authorization Quantity limit 1 per 1 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$66.0856	$1,982.5730 units	Prior authorization Quantity limit 1 per 1 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$259.5418	$778.633 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$277.3316	$831.993 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$259.5418	$778.633 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$319.8218	$959.473 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$44.2488	—	Prior authorization
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.9204	$692.763 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$44.3363	—	Prior authorization
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$277.3316	$831.993 units	Prior authorization Quantity limit 3 per 30 days

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

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$260.5100	$781.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$260.5100	$781.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	$100.233 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days

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

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$28.0304	$84.093 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$289.9940	$869.983 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$289.9940	$869.983 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6020	$694.813 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3744	—	Prior authorization
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$34.4791	—	Prior authorization
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$28.6706	$86.013 units	Prior authorization Quantity limit 3 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3857	—	Prior authorization
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$283.2956	$849.893 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$283.2956	$849.893 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$227.4907	$682.473 units	Prior authorization Quantity limit 3 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$62.4052	$187.223 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$227.5505	$682.653 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.7688	—	Prior authorization

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

New Mexico — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.4703	$1,015.413 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.2625	$1,014.793 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.6359	$712.913 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.4825	—	Prior authorization
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$60.7181	—	Prior authorization
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$376.6078	$1,129.823 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$23.6880	$71.063 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$15.7920	$47.383 units	Prior authorization Quantity limit 3 per 30 days

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

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.7847	$692.353 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$268.2949	$804.883 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$268.2949	$804.883 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.6996	$692.103 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$313.9775	$941.933 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$313.9775	$941.933 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.1869	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6125	$694.843 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.6528	—	Prior authorization
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$260.5100	$781.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$260.5100	$781.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days

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

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$269.1940	$807.583 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$269.1940	$807.583 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$69.2643	$207.793 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3886	—	Prior authorization
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.5923	—	Prior authorization
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$69.2643	$207.793 units	Prior authorization Quantity limit 3 per 30 days

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

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$314.5928	$943.783 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$314.5928	$943.783 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$220.7421	$662.233 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3750	—	Prior authorization
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$220.7483	$662.243 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.3750	—	Prior authorization

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

Indiana and Kentucky — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$273.7110	$821.133 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$273.7110	$821.133 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5961	$694.793 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4001	—	Prior authorization
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.7111	—	Prior authorization

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

Wisconsin — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.8398	$878.523 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.8398	$878.523 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3691	—	Prior authorization
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6038	$694.813 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$34.6373	—	Prior authorization

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

Missouri — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.2625	$1,014.793 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.4703	$1,015.413 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.8330	$713.503 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.6359	$712.913 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$259.4551	$778.373 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$259.4551	$778.373 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

Louisiana — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.0900	$774.273 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.0900	$774.273 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

Colorado — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.0900	$774.273 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.0900	$774.273 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

Arizona — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.4703	$1,015.413 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.2625	$1,014.793 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.6359	$712.913 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.8330	$713.503 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$273.3284	$819.993 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$481.6400	$1,444.923 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$481.6400	$1,444.923 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.1416	—	Prior authorization
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$41.4270	—	Prior authorization
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$303.6979	$911.093 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$301.9292	$905.793 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$228.2449	$684.733 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$228.1735	$684.523 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

Idaho and Utah — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$253.5223	$760.573 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$253.5223	$760.573 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$332.0590	$996.183 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$222.7454	$668.243 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$222.7871	$668.363 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

Maine and New Hampshire — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.0900	$774.273 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.0900	$774.273 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$269.6496	$808.953 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$269.6496	$808.953 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.3995	—	Prior authorization
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.7309	—	Prior authorization
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days

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

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.4703	$1,015.413 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$237.6359	$712.913 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$338.2625	$1,014.793 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.4825	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$376.6078	$1,129.823 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$60.7181	—	Prior authorization
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days

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

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$33.4102	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$320.3600	$961.083 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.4411	$775.323 units	Prior authorization Quantity limit 3 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$258.4411	$775.323 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$292.1770	$876.533 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$33.4102	—	Prior authorization

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

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.5900	$694.773 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.6800	$695.043 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$33.4102	—	Prior authorization

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$63.5926	—	Prior authorization

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

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	5Specialty Tier	25%	25%	$63.5926	—	Prior authorization

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

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	5Specialty Tier	25%	25%	$63.5926	—	Prior authorization

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

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	5Specialty Tier	25%	25%	$63.5926	—	Prior authorization

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

Coverage by region

Plan-by-plan detail