SAJAZIR 30 mg/3mL Injection (Icatibant) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	8 of 12	5	—	8 of 8 plans
Pennsylvania and West Virginia	8 of 12	5	—	8 of 8 plans
North Carolina	8 of 12	5	—	8 of 8 plans
Alabama and Tennessee	8 of 12	5	—	8 of 8 plans
Illinois	8 of 12	5	—	8 of 8 plans
Arkansas	8 of 12	5	—	8 of 8 plans
Texas	8 of 12	5	—	8 of 8 plans
Kansas	8 of 12	5	—	8 of 8 plans
California	8 of 12	5	—	8 of 8 plans
Connecticut, Massachusetts, Rhode Island and Vermont	7 of 11	5	—	7 of 7 plans
Oklahoma	7 of 11	5	—	7 of 7 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	7 of 11	5	—	7 of 7 plans
New Mexico	7 of 11	5	—	7 of 7 plans
New York	6 of 10	5	—	6 of 6 plans
Delaware, DC and Maryland	6 of 10	5	—	6 of 6 plans
South Carolina	6 of 11	5	—	6 of 6 plans
Georgia	6 of 10	5	—	6 of 6 plans
Florida	6 of 10	5	—	6 of 6 plans
Michigan	6 of 12	5	—	6 of 6 plans
Ohio	6 of 10	5	—	6 of 6 plans
Indiana and Kentucky	6 of 10	5	—	6 of 6 plans
Wisconsin	6 of 10	5	—	6 of 6 plans
Missouri	6 of 10	5	—	6 of 6 plans
Mississippi	6 of 10	5	—	6 of 6 plans
Louisiana	6 of 10	5	—	6 of 6 plans
Colorado	6 of 10	5	—	6 of 6 plans
Arizona	6 of 10	5	—	6 of 6 plans
Nevada	6 of 10	5	—	6 of 6 plans
Oregon and Washington	6 of 10	5	—	6 of 6 plans
Idaho and Utah	6 of 10	5	—	6 of 6 plans
Maine and New Hampshire	5 of 9	5	—	5 of 5 plans
Virginia	5 of 9	5	—	5 of 5 plans
Alaska	5 of 9	5	—	5 of 5 plans
Hawaii	4 of 8	5	—	4 of 4 plans
Puerto Rico	2 of 3	5	—	2 of 2 plans
American Samoa	no PDP	—	—	—
Guam	no PDP	—	—	—
Northern Mariana Islands	no PDP	—	—	—
U.S. Virgin Islands	no PDP	—	—	—

New Jersey — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$567.6182	$10,217.1318 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$567.6182	$10,217.1318 units	Prior authorization Quantity limit 18 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1750.9001	$47,274.3027 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$471.4238	$8,485.6318 units	Prior authorization Quantity limit 18 per 30 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$478.6595	$8,615.8718 units	Prior authorization Quantity limit 18 per 30 days

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

North Carolina — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$565.6978	$10,182.5618 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$565.6978	$10,182.5618 units	Prior authorization Quantity limit 18 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$608.3385	$10,950.0918 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1750.9001	$47,274.3027 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$608.3385	$10,950.0918 units	Prior authorization Quantity limit 18 per 30 days

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

Illinois — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$271.6700	$4,890.0618 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1750.9001	$47,274.3027 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$271.6700	$4,890.0618 units	Prior authorization Quantity limit 18 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 — 8 plans, 8 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1745.7854	$47,136.2127 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1745.7854	$47,136.2127 units	Prior authorization Quantity limit 27 per 30 days

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

Texas — 8 plans, 8 with restrictions

Maximum premiumMaximum deductiblePlan familyPlanSort by

Showing 8 of 8 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$575.3303	$10,355.9518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$538.0620	$9,685.1218 units	Prior authorization Quantity limit 18 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 — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$697.3657	$12,552.5818 units	Prior authorization Quantity limit 18 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$708.2734	$12,748.9218 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$708.2734	$12,748.9218 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

California — 8 plans, 8 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$495.6245	$8,921.2418 units	Prior authorization Quantity limit 36 per 60 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$495.6245	$8,921.2418 units	Prior authorization Quantity limit 36 per 60 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$2128.0716	$57,457.9327 units	Prior authorization Quantity limit 27 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$2128.0716	$57,457.9327 units	Prior authorization Quantity limit 27 per 30 days

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

Oklahoma — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$580.4864	$10,448.7618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$536.6915	$9,660.4518 units	Prior authorization Quantity limit 18 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 — 7 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$613.6940	$11,046.4918 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days

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

New Mexico — 7 plans, 7 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$536.4027	$9,655.2518 units	Prior authorization Quantity limit 18 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$567.6711	$10,218.0818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1694.4300	$30,499.7418 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1694.4300	$30,499.7418 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1750.9001	$47,274.3027 units	Prior authorization Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Maximum premiumMaximum deductiblePlan familyPlanSort by

Showing 6 of 6 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$584.4769	$10,520.5818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$584.4769	$10,520.5818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Indiana and Kentucky — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Wisconsin — 6 plans, 6 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Missouri — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days

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

Louisiana — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Colorado — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Arizona — 6 plans, 6 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 6 plans, 6 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Idaho and Utah — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days

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

Maine and New Hampshire — 5 plans, 5 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 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 — 5 plans, 5 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 · $0 with full Extra Help	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 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 — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$2476.2047	$66,857.5327 units	Prior authorization Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1238.6380	$22,295.4818 units	Prior authorization Quantity limit 18 per 30 days

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

Puerto Rico — 2 plans, 2 with restrictions

Maximum premiumMaximum deductiblePlanSort by

Showing 2 of 2 plans

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%	—	$1725.3586	$31,056.4518 units	Prior authorization Quantity limit 18 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1717.6868	$30,918.3618 units	Prior authorization Quantity limit 18 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.

SAJAZIR 30 mg/3mL Injection

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No stand-alone Part D plan in American Samoa

No stand-alone Part D plan in Guam

No stand-alone Part D plan in Northern Mariana Islands

No stand-alone Part D plan in U.S. Virgin Islands