XCOPRI TITRATION PACK Kit (Cenobamate) — Medicare Part D coverage and cost

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

New Jersey — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.9294	$117.8830 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7418	$18.715 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.7418	$18.715 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$3.9294	$117.8830 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8633	$19.325 units	Prior authorization Quantity limit 56 per 365 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$4.1950	—	None
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$4.1763	$20.885 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.8633	$19.325 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9294	$117.8830 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$4.1763	$20.885 units	Prior authorization Quantity limit 56 per 365 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$4.1950	—	None

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

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	4Non-Preferred Drug	33%	—	$3.9054	$117.1630 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7647	$18.825 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$3.7647	$18.825 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.9054	$117.1630 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$4.1318	$20.665 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8422	$19.215 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8453	$19.235 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$4.1318	$20.665 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9054	$117.1630 units	Prior authorization Quantity limit 28 per 28 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$3.8526	—	Prior authorization
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$3.8508	—	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.

North Carolina — 12 plans, 10 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	4Non-Preferred Drug	40%	40%	$3.7719	$18.865 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7719	$18.865 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.9262	$117.7930 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9262	$117.7930 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$4.1869	$20.935 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8784	$19.395 units	Prior authorization Quantity limit 56 per 365 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.2297	—	None
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.8856	$19.435 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9262	$117.7930 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$4.1869	$20.935 units	Prior authorization Quantity limit 56 per 365 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$4.2297	—	None

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

Alabama and Tennessee — 12 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	4Non-Preferred Drug	34%	—	$3.9044	$117.1330 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7605	$18.805 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7605	$18.805 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.9044	$117.1330 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$4.1566	$20.785 units	Prior authorization Quantity limit 56 per 365 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$4.1817	—	None
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8359	$19.185 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.8423	$19.215 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0232	$120.7030 units	Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9044	$117.1330 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1566	$20.785 units	Prior authorization Quantity limit 56 per 365 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$4.1817	—	None

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

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	4Non-Preferred Drug	28%	28%	$3.7144	$18.575 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7144	$18.575 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.7798	$18.905 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.9063	$117.1930 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.9063	$117.1930 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$4.1239	$20.625 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.7753	$18.885 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$4.1239	$20.625 units	Prior authorization Quantity limit 56 per 365 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$3.9162	$19.585 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9063	$117.1930 units	Prior authorization Quantity limit 28 per 28 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	4Non-Preferred Drug	27%	27%	$3.9162	$19.585 units	Prior authorization Quantity limit 56 per 365 days

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

Illinois — 12 plans, 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	4Non-Preferred Drug	31%	31%	$3.7958	$18.985 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7958	$18.985 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.9373	$118.1230 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$3.9373	$118.1230 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$4.1907	$20.955 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8844	$19.425 units	Prior authorization Quantity limit 56 per 365 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$4.2255	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0201	$120.6030 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$4.1907	$20.955 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.8888	$19.445 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9373	$118.1230 units	Prior authorization Quantity limit 28 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.1706	—	None

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

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	4Non-Preferred Drug	26%	26%	$3.7473	$18.745 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7473	$18.745 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.8100	$19.055 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.8900	$116.7030 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.8900	$116.7030 units	Prior authorization Quantity limit 28 per 28 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$3.9659	$118.9830 units	Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8067	$19.035 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$4.2010	$21.005 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8900	$116.7030 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$4.2010	$21.005 units	Prior authorization Quantity limit 56 per 365 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$3.9659	$118.9830 units	Quantity limit 28 per 28 days

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

Texas — 12 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	4Non-Preferred Drug	29%	29%	$3.7497	$18.755 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7497	$18.755 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.8896	$116.6930 units	Prior authorization Quantity limit 28 per 28 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.8896	$116.6930 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8283	$19.145 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$4.1634	$20.825 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$4.1682	—	None
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8274	$19.145 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1634	$20.825 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8896	$116.6930 units	Prior authorization Quantity limit 28 per 28 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.1218	—	None

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

Kansas — 12 plans, 9 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	4Non-Preferred Drug	30%	30%	$4.2601	—	None
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.2601	—	None
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8527	$19.265 units	Prior authorization Quantity limit 56 per 365 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7980	$18.995 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$3.7980	$18.995 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.9187	$117.5630 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$3.9187	$117.5630 units	Prior authorization Quantity limit 28 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$4.2601	—	None
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0510	$121.5330 units	Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$4.1462	$20.735 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9187	$117.5630 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	4Non-Preferred Drug	38%	—	$4.1462	$20.735 units	Prior authorization Quantity limit 56 per 365 days

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

California — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.8630	$19.325 units	Prior authorization Quantity limit 56 per 365 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7282	$18.645 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.7282	$18.645 units	Quantity limit 28 per 180 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8637	$19.325 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$3.9361	$118.0830 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$4.1425	$20.715 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.9361	$118.0830 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	4Non-Preferred Drug	31%	—	$4.1425	$20.715 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9361	$118.0830 units	Prior authorization Quantity limit 28 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	4Non-Preferred Drug	49%	49%	$4.0234	$120.7030 units	Prior authorization Quantity limit 28 per 28 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	4Non-Preferred Drug	37%	37%	$4.0234	$120.7030 units	Prior authorization Quantity limit 28 per 28 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 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	4Non-Preferred Drug	32%	—	$3.9374	$118.1230 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7279	$18.645 units	Quantity limit 28 per 180 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.8994	$116.9830 units	Quantity limit 28 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.7279	$18.645 units	Quantity limit 28 per 180 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$4.1384	$20.695 units	Prior authorization Quantity limit 56 per 365 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$3.9374	$118.1230 units	Prior authorization Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9374	$118.1230 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8713	$19.365 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$4.1384	$20.695 units	Prior authorization Quantity limit 56 per 365 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	4Non-Preferred Drug	35%	35%	$3.8994	$116.9830 units	Quantity limit 28 per 28 days

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

South Carolina — 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	4Non-Preferred Drug	40%	40%	$3.7676	$18.845 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7676	$18.845 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$3.9261	$117.7830 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9261	$117.7830 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8383	$19.195 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$4.1699	$20.855 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1699	$20.855 units	Prior authorization Quantity limit 56 per 365 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$3.9388	—	Prior authorization
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9261	$117.7830 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8486	$19.245 units	Prior authorization Quantity limit 56 per 365 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, 9 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	4Non-Preferred Drug	40%	40%	$4.1289	—	None
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$3.8905	$116.7130 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.8921	$19.465 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$3.8921	$19.465 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$3.8905	$116.7130 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.9589	$19.795 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$4.1875	$20.945 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8905	$116.7130 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$4.1875	$20.945 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.9589	$19.795 units	Prior authorization Quantity limit 56 per 365 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.1238	—	None

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.9094	$117.2830 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$4.1394	$20.705 units	Prior authorization Quantity limit 56 per 365 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7925	$18.965 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7925	$18.965 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9094	$117.2830 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8251	$19.135 units	Prior authorization Quantity limit 56 per 365 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$4.2305	—	None
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9094	$117.2830 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8295	$19.155 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1394	$20.705 units	Prior authorization Quantity limit 56 per 365 days

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

New Mexico — 11 plans, 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	4Non-Preferred Drug	31%	31%	$3.7842	$18.925 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7842	$18.925 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.8275	$19.145 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.8905	$116.7130 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$4.1718	$20.865 units	Prior authorization Quantity limit 56 per 365 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$3.8905	$116.7130 units	Prior authorization Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8905	$116.7130 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1718	$20.865 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.1492	—	None
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.1917	—	None

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

New York — 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	4Non-Preferred Drug	29%	29%	$3.7689	$18.845 units	Prior authorization Quantity limit 56 per 365 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7070	$18.545 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$3.7070	$18.545 units	Quantity limit 28 per 180 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.7698	$18.855 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$4.1295	$20.655 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$3.8865	$116.5930 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$3.8865	$116.5930 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	4Non-Preferred Drug	28%	—	$4.1295	$20.655 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8865	$116.5930 units	Prior authorization Quantity limit 28 per 28 days

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

Delaware, DC and Maryland — 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	4Non-Preferred Drug	33%	—	$3.9401	$118.2030 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.9401	$118.2030 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7502	$18.755 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.7502	$18.755 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8778	$19.395 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$4.1497	$20.755 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.8772	$19.395 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1497	$20.755 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9401	$118.2030 units	Prior authorization Quantity limit 28 per 28 days

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

Georgia — 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	4Non-Preferred Drug	28%	28%	$3.7560	$18.785 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7560	$18.785 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$3.9180	$117.5430 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9180	$117.5430 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8225	$19.115 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$4.1460	$20.735 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9180	$117.5430 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$4.1460	$20.735 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8375	$19.195 units	Prior authorization Quantity limit 56 per 365 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, 8 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	4Non-Preferred Drug	28%	28%	$3.7555	$18.785 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7555	$18.785 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.9361	$118.0830 units	Prior authorization Quantity limit 28 per 28 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$3.9361	$118.0830 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.2576	—	None
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$4.1877	$20.945 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9361	$118.0830 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1877	$20.945 units	Prior authorization Quantity limit 56 per 365 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$4.2576	—	None

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

Ohio — 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	4Non-Preferred Drug	31%	—	$3.9265	$117.8030 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.8008	$19.005 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.8008	$19.005 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9265	$117.8030 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8672	$19.345 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$4.1692	$20.855 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0201	$120.6030 units	Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$3.8763	$19.385 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9265	$117.8030 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$4.1692	$20.855 units	Prior authorization Quantity limit 56 per 365 days

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

Indiana and Kentucky — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.9209	$117.6330 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7554	$18.785 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7554	$18.785 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9209	$117.6330 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8535	$19.275 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$4.1652	$20.835 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8557	$19.285 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9209	$117.6330 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1652	$20.835 units	Prior authorization Quantity limit 56 per 365 days

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

Wisconsin — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$3.7477	$18.745 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7477	$18.745 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8006	$19.005 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.9017	$117.0530 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$3.9017	$117.0530 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$4.1871	$20.945 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0400	$121.2030 units	Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$3.7986	$18.995 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9017	$117.0530 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$4.1871	$20.945 units	Prior authorization Quantity limit 56 per 365 days

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

Missouri — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7737	$18.875 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$3.7737	$18.875 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.9043	$117.1330 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9043	$117.1330 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8498	$19.255 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$4.1493	$20.755 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8498	$19.255 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0459	$121.3830 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1493	$20.755 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9043	$117.1330 units	Prior authorization Quantity limit 28 per 28 days

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

Mississippi — 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	4Non-Preferred Drug	29%	29%	$3.7965	$18.985 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7965	$18.985 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$3.8962	$116.8930 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$3.8962	$116.8930 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8550	$19.275 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8496	$19.255 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$4.1897	$20.955 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8962	$116.8930 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1897	$20.955 units	Prior authorization Quantity limit 56 per 365 days

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

Louisiana — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$3.9024	$117.0730 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7587	$18.795 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$3.7587	$18.795 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$3.9024	$117.0730 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$4.1984	$20.995 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8491	$19.255 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8491	$19.255 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9024	$117.0730 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$4.1984	$20.995 units	Prior authorization Quantity limit 56 per 365 days

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

Colorado — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.8408	$19.205 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$3.9368	$118.1030 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.8408	$19.205 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9368	$118.1030 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.9070	$19.545 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8932	$19.475 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$4.2071	$21.045 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9368	$118.1030 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$4.2071	$21.045 units	Prior authorization Quantity limit 56 per 365 days

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

Arizona — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$3.8291	$19.155 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.8291	$19.155 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$3.9140	$19.575 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$3.9319	$117.9630 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9319	$117.9630 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$4.1568	$20.785 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.9134	$19.575 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0211	$120.6330 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1568	$20.785 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9319	$117.9630 units	Prior authorization Quantity limit 28 per 28 days

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

Nevada — 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	4Non-Preferred Drug	32%	—	$3.9693	$119.0830 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.9450	$19.725 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.9450	$19.725 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$3.9693	$119.0830 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.9650	$19.825 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$4.1775	$20.895 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.9913	$19.965 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$4.1775	$20.895 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9693	$119.0830 units	Prior authorization Quantity limit 28 per 28 days

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

Oregon and Washington — 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	4Non-Preferred Drug	28%	28%	$3.7994	$19.005 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7994	$19.005 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8475	$19.245 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.9136	$117.4130 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.9136	$117.4130 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$4.1381	$20.695 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8460	$19.235 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9136	$117.4130 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$4.1381	$20.695 units	Prior authorization Quantity limit 56 per 365 days

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

Idaho and Utah — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.8968	$116.9030 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7920	$18.965 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$3.8968	$116.9030 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7920	$18.965 units	Quantity limit 28 per 180 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0212	$120.6430 units	Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8149	$19.075 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$4.1737	$20.875 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8968	$116.9030 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8237	$19.125 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$4.1737	$20.875 units	Prior authorization Quantity limit 56 per 365 days

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

Maine and New Hampshire — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$3.7742	$18.875 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7742	$18.875 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8476	$19.245 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.9087	$117.2630 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$3.9087	$117.2630 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$4.1862	$20.935 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0209	$120.6330 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$4.1862	$20.935 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9087	$117.2630 units	Prior authorization Quantity limit 28 per 28 days

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

Virginia — 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	4Non-Preferred Drug	31%	31%	$3.7825	$18.915 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7825	$18.915 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.9219	$117.6630 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$3.9219	$117.6630 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$4.1529	$20.765 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9219	$117.6630 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1529	$20.765 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.8753	$19.385 units	Prior authorization Quantity limit 56 per 365 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	4Non-Preferred Drug	28%	28%	$4.8500	$24.255 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$4.8500	$24.255 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$3.8399	$115.2030 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$3.8399	$115.2030 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.8500	$24.255 units	Quantity limit 28 per 180 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$4.1017	$20.515 units	Prior authorization Quantity limit 56 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$4.1017	$20.515 units	Prior authorization Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.8399	$115.2030 units	Prior authorization Quantity limit 28 per 28 days

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

Hawaii — 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	4Non-Preferred Drug	38%	—	$4.1105	$20.555 units	Prior authorization Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	—	$3.9900	$119.7030 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0198	$120.5930 units	Quantity limit 28 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.7377	$18.695 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$3.7377	$18.695 units	Quantity limit 28 per 180 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	4Non-Preferred Drug	30%	—	$3.9900	$119.7030 units	Prior authorization Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$3.9900	$119.7030 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$4.1105	$20.555 units	Prior authorization Quantity limit 56 per 365 days

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

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.7950	$18.985 units	Prior authorization Quantity limit 56 per 365 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$3.7950	$18.985 units	Prior authorization Quantity limit 56 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.1705	$20.855 units	Prior authorization Quantity limit 56 per 365 days

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

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.2665	$21.335 units	Prior authorization Quantity limit 56 per 365 days

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

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.2665	$21.335 units	Prior authorization Quantity limit 56 per 365 days

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

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.2665	$21.335 units	Prior authorization Quantity limit 56 per 365 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.2665	$21.335 units	Prior authorization Quantity limit 56 per 365 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.

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Plan-by-plan detail