PREGABALIN 200 mg Capsule

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	3–4	$45.00	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	2–4	$5.00	12 of 12 plans
North Carolina	12 of 12	3–4	$45.00	12 of 12 plans
Alabama and Tennessee	12 of 12	3–4	$45.00	12 of 12 plans
Michigan	12 of 12	2–4	$5.00	12 of 12 plans
Illinois	12 of 12	3–4	$45.00	12 of 12 plans
Arkansas	12 of 12	3–4	$45.00	12 of 12 plans
Texas	12 of 12	3–4	$45.00	12 of 12 plans
Kansas	12 of 12	3–4	$45.00	12 of 12 plans
California	12 of 12	3–4	$45.00	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	3–4	$30.00	11 of 11 plans
South Carolina	11 of 11	2–4	$17.00	11 of 11 plans
Oklahoma	11 of 11	3–4	$45.00	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	3–4	$45.00	11 of 11 plans
New Mexico	11 of 11	3–4	$45.00	11 of 11 plans
New York	10 of 10	3–4	$45.00	10 of 10 plans
Delaware, DC and Maryland	10 of 10	3–4	$45.00	10 of 10 plans
Georgia	10 of 10	3–4	$45.00	10 of 10 plans
Florida	10 of 10	3–4	$45.00	10 of 10 plans
Ohio	10 of 10	3–4	$45.00	10 of 10 plans
Indiana and Kentucky	10 of 10	3–4	$45.00	10 of 10 plans
Wisconsin	10 of 10	3–4	$45.00	10 of 10 plans
Missouri	10 of 10	3–4	$45.00	10 of 10 plans
Mississippi	10 of 10	3–4	$45.00	10 of 10 plans
Louisiana	10 of 10	3–4	$45.00	10 of 10 plans
Colorado	10 of 10	3–4	$45.00	10 of 10 plans
Arizona	10 of 10	3–4	$45.00	10 of 10 plans
Nevada	10 of 10	3–4	$45.00	10 of 10 plans
Oregon and Washington	10 of 10	3–4	$45.00	10 of 10 plans
Idaho and Utah	10 of 10	3–4	$45.00	10 of 10 plans
Maine and New Hampshire	9 of 9	3–4	$45.00	9 of 9 plans
Virginia	9 of 9	3–4	$45.00	9 of 9 plans
Alaska	9 of 9	3–4	$45.00	9 of 9 plans
Hawaii	8 of 8	3–4	$45.00	8 of 8 plans
Puerto Rico	3 of 3	3–4	—	3 of 3 plans
American Samoa	1 of 1	3	—	1 of 1 plans
Guam	1 of 1	3	—	1 of 1 plans
Northern Mariana Islands	1 of 1	3	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	3	—	1 of 1 plans

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1246	$1.129 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.1252	$1.139 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.2332	$2.109 units	Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2640	$2.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1093	$0.989 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2468	$20.229 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1242	$1.129 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1160	$1.049 units	Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	3Preferred Brand	20%	20%	$0.2640	$2.389 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3891	$3.509 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.3891	$3.509 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.1667	$1.509 units	Quantity limit 9 per 30 days

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

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.0947	$8.5290 units	Prior authorization Quantity limit 93 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.0947	$8.5290 units	Prior authorization Quantity limit 93 per 31 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1157	$1.049 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1170	$1.059 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.2351	$20.129 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.1029	$0.939 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2103	$1.899 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.1046	$0.949 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1151	$1.049 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3720	$3.359 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3721	$3.359 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1737	$1.569 units	Quantity limit 9 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 — 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)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1236	$1.119 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1250	$1.129 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0985	$0.899 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2732	$2.469 units	Quantity limit 9 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2959	$2.669 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2287	$20.069 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1229	$1.119 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.0985	$0.899 units	Quantity limit 9 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$135.00	$0.2959	$2.669 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3597	$3.249 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3597	$3.249 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.1949	$1.759 units	Quantity limit 9 per 30 days

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

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1231	$1.119 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1245	$1.129 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.0989	$0.899 units	Quantity limit 9 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2656	$2.399 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2709	$2.449 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2355	$20.129 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1224	$1.109 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.0991	$0.899 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3434	$3.099 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3434	$3.099 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.1881	$1.699 units	Quantity limit 9 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$0.2656	$2.399 units	Quantity limit 9 per 30 days

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

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	2Generic	$5.00	$15.00	$0.0758	$0.689 units	Quantity limit 27 per 90 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	2Generic	$5.00	$10.00	$0.0758	$0.689 units	Quantity limit 27 per 90 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1213	$1.099 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1222	$1.109 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1013	$0.919 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2299	$2.079 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2381	$20.149 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.1018	$0.929 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1208	$1.099 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3320	$2.999 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3320	$2.999 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1614	$1.459 units	Quantity limit 9 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1275	$1.159 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1286	$1.169 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1046	$0.949 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3698	$3.339 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.3083	$2.779 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2337	$20.109 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1074	$0.979 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1269	$1.149 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3012	$2.719 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4393	$3.959 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4393	$3.959 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.2237	$2.019 units	Quantity limit 9 per 30 days

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

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1138	$1.029 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1161	$1.049 units	Quantity limit 9 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.4097	$3.699 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2465	$2.229 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.1042	$0.949 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2355	$20.129 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1126	$1.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.1042	$0.949 units	Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.4097	$3.699 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.2720	$2.459 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2720	$2.459 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.1923	$1.739 units	Quantity limit 9 per 30 days

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

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1251	$1.139 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1237	$1.119 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2710	$2.449 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0989	$0.899 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2306	$20.089 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2685	$2.429 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.0989	$0.899 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1229	$1.119 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.2785	$2.519 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4092	$3.689 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4092	$3.689 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1861	$1.679 units	Quantity limit 9 per 30 days

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

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3375	$3.049 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1164	$1.059 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1188	$1.079 units	Quantity limit 9 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.3375	$3.049 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.1946	$19.759 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1141	$1.039 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1151	$1.049 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1208	$1.099 units	Quantity limit 9 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.3208	$2.899 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.2254	$2.039 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3855	$3.479 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3855	$3.479 units	Quantity limit 9 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 — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2507	$2.269 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2287	$20.069 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1233	$1.119 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1005	$0.909 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1225	$1.109 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1015	$0.919 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1221	$1.109 units	Quantity limit 9 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$0.2485	$14.9160 units	Quantity limit 2 per 1 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.1777	$1.609 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3875	$3.499 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.3875	$3.499 units	Quantity limit 9 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	4Non-Preferred Drug	49%	49%	$0.2485	$14.9160 units	Quantity limit 2 per 1 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1242	$1.129 units	Quantity limit 9 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1799	$1.629 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.2104	$19.899 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1099	$0.999 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1247	$1.129 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1239	$1.129 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1118	$1.019 units	Quantity limit 9 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$0.1799	$1.629 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4075	$3.679 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4075	$3.679 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1674	$1.519 units	Quantity limit 9 per 30 days

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

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	2Generic	$17.00	$42.50	$0.1402	$1.269 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1211	$1.099 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.1227	$1.109 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2496	$2.259 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2370	$20.139 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0980	$0.889 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.0983	$0.889 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1203	$1.089 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3860	$3.479 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3860	$3.479 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1908	$1.729 units	Quantity limit 9 per 30 days

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

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.2993	$2.699 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1188	$1.079 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1210	$1.099 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2756	$2.489 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.0987	$0.899 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1177	$1.069 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.0990	$0.899 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3221	$2.909 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2983	$2.689 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.2983	$2.689 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2026	$1.829 units	Quantity limit 9 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1175	$1.069 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1091	$0.989 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1190	$1.079 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.1821	$19.649 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2482	$2.239 units	Quantity limit 9 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.3350	$3.029 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1167	$1.059 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.1092	$0.989 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3805	$3.429 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3805	$3.429 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1790	$1.619 units	Quantity limit 9 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 — 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)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1304	$1.179 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.1003	$0.909 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1331	$1.209 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1290	$1.169 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.1009	$0.919 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2013	$19.819 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3382	$3.049 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4195	$3.789 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4195	$3.789 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2666	$2.409 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.3466	$3.129 units	Quantity limit 9 per 30 days

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

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2054	$1.859 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1017	$0.929 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2320	$20.099 units	Prior authorization Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1206	$1.099 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$0.1211	$1.099 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1029	$0.939 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1203	$1.089 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.1520	$1.379 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3368	$3.039 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3368	$3.039 units	Quantity limit 9 per 30 days

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

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1225	$1.109 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1233	$1.119 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.0987	$0.899 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2456	$2.219 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.0992	$0.899 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2223	$20.009 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1221	$1.109 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3696	$3.339 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.3696	$3.339 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1688	$1.529 units	Quantity limit 9 per 30 days

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

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1191	$1.079 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1204	$1.089 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2382	$2.149 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0984	$0.899 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2220	$20.009 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1184	$1.079 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.0985	$0.899 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3538	$3.189 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3538	$3.189 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1801	$1.629 units	Quantity limit 9 per 30 days

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

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1289	$1.169 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1281	$1.159 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2331	$20.109 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2569	$2.319 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0995	$0.909 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1276	$1.159 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1005	$0.909 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4155	$3.749 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4155	$3.749 units	Quantity limit 9 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2569	$2.319 units	Quantity limit 9 per 30 days

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

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1203	$1.089 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1216	$1.099 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2670	$2.409 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.1004	$0.909 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2146	$19.939 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1195	$1.089 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1008	$0.919 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4152	$3.749 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4152	$3.749 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1979	$1.789 units	Quantity limit 9 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 — 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	3Preferred Brand	25%	20%	$0.1201	$1.089 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1215	$1.099 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.2360	$20.129 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2527	$2.279 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1101	$0.999 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1194	$1.079 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.1101	$0.999 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3684	$3.329 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3684	$3.329 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1921	$1.739 units	Quantity limit 9 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 — 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	3Preferred Brand	25%	20%	$0.1293	$1.169 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1309	$1.189 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.0992	$0.899 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.1934	$19.749 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3237	$2.919 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1284	$1.169 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.0992	$0.899 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3469	$3.129 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3469	$3.129 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.2079	$1.879 units	Quantity limit 9 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 — 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)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1208	$1.099 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1231	$1.119 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2839	$2.569 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1007	$0.919 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2205	$19.989 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1015	$0.919 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1196	$1.089 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3536	$3.189 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3536	$3.189 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.2100	$1.899 units	Quantity limit 9 per 30 days

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

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1181	$1.069 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1198	$1.089 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2512	$2.269 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.0991	$0.899 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1172	$1.059 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2278	$20.059 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.0996	$0.909 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2749	$2.479 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2749	$2.479 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1853	$1.679 units	Quantity limit 9 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 — 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	3Preferred Brand	25%	20%	$0.1247	$1.129 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1264	$1.149 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.0981	$0.889 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.2404	$20.169 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2689	$2.429 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1238	$1.119 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.0982	$0.889 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3128	$2.829 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3128	$2.829 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1913	$1.729 units	Quantity limit 9 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 — 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	3Preferred Brand	25%	20%	$0.1214	$1.099 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1234	$1.119 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3612	$3.259 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.1914	$19.729 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1008	$0.919 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1204	$1.089 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1008	$0.919 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4234	$3.819 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4234	$3.819 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.2402	$2.169 units	Quantity limit 9 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 — 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	3Preferred Brand	23%	18%	$0.1309	$1.189 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1325	$1.199 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.1006	$0.919 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3811	$3.439 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2040	$19.849 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.1011	$0.919 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1300	$1.179 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.4497	$4.059 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4497	$4.059 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2392	$2.159 units	Quantity limit 9 per 30 days

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

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1278	$1.159 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1297	$1.179 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3420	$3.089 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1014	$0.919 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2396	$20.169 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.1022	$0.929 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1268	$1.149 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4579	$4.129 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4579	$4.129 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.2305	$2.079 units	Quantity limit 9 per 30 days

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

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1172	$1.059 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1186	$1.079 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1033	$0.939 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.3387	$3.059 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.1804	$19.629 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1165	$1.059 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.1045	$0.949 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4014	$3.619 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4014	$3.619 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.2161	$1.949 units	Quantity limit 9 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 — 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	3Preferred Brand	25%	20%	$0.1161	$1.049 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1178	$1.069 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.2154	$19.949 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.2866	$2.589 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1005	$0.909 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1152	$1.049 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1006	$0.919 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3257	$2.939 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3257	$2.939 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.2014	$1.819 units	Quantity limit 9 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 — 9 plans, 9 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	3Preferred Brand	25%	20%	$0.1226	$1.109 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1243	$1.129 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1029	$0.939 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2192	$19.979 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1029	$0.939 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1217	$1.109 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4215	$3.799 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4215	$3.799 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1998	$1.809 units	Quantity limit 9 per 30 days

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

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1213	$1.099 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1233	$1.119 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.0989	$0.899 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2269	$20.049 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1202	$1.089 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.0991	$0.899 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4087	$3.689 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4087	$3.689 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.2108	$1.909 units	Quantity limit 9 per 30 days

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

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	19%	$0.1106	$1.009 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1120	$1.019 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.1300	$1.179 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.2176	$19.969 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.1301	$1.179 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1099	$0.999 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4087	$3.689 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2609	$2.359 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4087	$3.689 units	Quantity limit 9 per 30 days

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

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.0996	$0.909 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$0.1196	$1.089 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$2.1855	$19.679 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1207	$1.099 units	Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1190	$1.079 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1013	$0.919 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4500	$4.059 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.4500	$4.059 units	Quantity limit 9 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 — 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	3Preferred Brand	17%	17%	$0.3428	$3.099 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.0925	$0.839 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$0.1918	$1.739 units	Quantity limit 9 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.

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.3323	$2.999 units	Quantity limit 9 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.

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.3323	$2.999 units	Quantity limit 9 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.

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.3323	$2.999 units	Quantity limit 9 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.

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

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.0997	$0.909 units	Quantity limit 9 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.

Coverage by region

Plan-by-plan detail