FEBUXOSTAT 80 mg Tablet, Film Coated

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Michigan	7 of 12	3–4	—	4 of 7 plans
Pennsylvania and West Virginia	6 of 12	3–4	—	3 of 6 plans
Indiana and Kentucky	6 of 10	3–4	—	3 of 6 plans
Wisconsin	6 of 10	3–4	—	3 of 6 plans
Louisiana	6 of 10	3–4	—	3 of 6 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	6 of 11	3–4	—	3 of 6 plans
Idaho and Utah	6 of 10	3–4	—	3 of 6 plans
California	6 of 12	3–4	—	3 of 6 plans
Connecticut, Massachusetts, Rhode Island and Vermont	5 of 11	3–4	—	3 of 5 plans
New York	5 of 10	3–4	—	2 of 5 plans
New Jersey	5 of 12	3–4	—	2 of 5 plans
Delaware, DC and Maryland	5 of 10	3–4	—	2 of 5 plans
North Carolina	5 of 12	3–4	—	2 of 5 plans
South Carolina	5 of 11	3–4	—	2 of 5 plans
Georgia	5 of 10	3–4	—	2 of 5 plans
Alabama and Tennessee	5 of 12	3–4	—	2 of 5 plans
Ohio	5 of 10	3–4	—	2 of 5 plans
Illinois	5 of 12	3–4	—	2 of 5 plans
Missouri	5 of 10	3–4	—	2 of 5 plans
Arkansas	5 of 12	3–4	—	2 of 5 plans
Mississippi	5 of 10	3–4	—	2 of 5 plans
Texas	5 of 12	3–4	—	2 of 5 plans
Oklahoma	5 of 11	3–4	—	2 of 5 plans
Colorado	5 of 10	3–4	—	2 of 5 plans
Arizona	5 of 10	3–4	—	2 of 5 plans
Nevada	5 of 10	3–4	—	2 of 5 plans
Oregon and Washington	5 of 10	3–4	—	2 of 5 plans
Maine and New Hampshire	4 of 9	3–4	—	2 of 4 plans
Virginia	4 of 9	3–4	—	2 of 4 plans
Kansas	4 of 12	3–4	—	2 of 4 plans
New Mexico	4 of 11	3–4	—	2 of 4 plans
Hawaii	4 of 8	3–4	—	3 of 4 plans
Alaska	4 of 9	3–4	—	2 of 4 plans
Florida	3 of 10	3–4	—	2 of 3 plans
Puerto Rico	3 of 3	3–4	—	1 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

Michigan — 7 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.1056	—	None
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4734	—	Step therapy
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$1.1969	$3.593 units	Step therapy Quantity limit 9 per 90 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$1.1969	$3.593 units	Step therapy Quantity limit 9 per 90 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.8218	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5505	—	None
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4715	—	Step therapy

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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.8591	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4776	—	Step therapy
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.9331	—	None
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.5672	—	Step therapy
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.4756	—	Step therapy
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5603	—	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.

Indiana and Kentucky — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0735	—	None
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4808	—	Step therapy
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.7732	—	None
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.5314	—	Step therapy
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$0.4808	—	Step therapy
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5966	—	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.

Wisconsin — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.4723	—	None
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4625	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.7679	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6121	—	None
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4625	—	Step therapy
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.6450	—	Step therapy

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

Louisiana — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2085	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4714	—	Step therapy
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.6671	—	None
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$0.4691	—	Step therapy
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.6922	—	Step therapy
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6400	—	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 — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0245	—	None
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4850	—	Step therapy
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4826	—	Step therapy
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.8258	—	None
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.9192	—	Step therapy
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5533	—	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.

Idaho and Utah — 6 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0641	—	None
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4900	—	Step therapy
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.5850	—	None
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.5033	—	Step therapy
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4900	—	Step therapy
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6229	—	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.

California — 6 plans, 3 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%	$0.8318	—	None
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4690	—	Step therapy
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5234	—	None
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.6419	—	None
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4677	—	Step therapy
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	4Non-Preferred Drug	37%	37%	$1.2931	$38.7930 units	Step therapy Quantity limit 1 per 1 days

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

Connecticut, Massachusetts, Rhode Island and Vermont — 5 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4956	—	Step therapy
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0918	—	None
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.4387	—	Step therapy
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4900	—	Step therapy
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4860	—	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 — 5 plans, 2 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%	$0.8063	—	None
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4731	—	Step therapy
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5255	—	None
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.4561	—	None
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4719	—	Step therapy

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

New Jersey — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.9058	—	None
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4803	—	Step therapy
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.6928	—	None
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4782	—	Step therapy
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.5263	—	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.

Delaware, DC and Maryland — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.9026	—	None
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4657	—	Step therapy
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0290	—	None
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5234	—	None
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4654	—	Step therapy

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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2141	—	None
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4637	—	Step therapy
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.7980	—	None
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4637	—	Step therapy
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5998	—	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.

South Carolina — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0589	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4667	—	Step therapy
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.8062	—	None
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4658	—	Step therapy
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5891	—	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.

Georgia — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.9959	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4678	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.7916	—	None
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4666	—	Step therapy
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5923	—	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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2056	—	None
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4675	—	Step therapy
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.7870	—	None
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4667	—	Step therapy
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.6297	—	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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.0747	—	None
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4707	—	Step therapy
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0753	—	None
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4707	—	Step therapy
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.5693	—	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.

Illinois — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.4462	—	None
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4776	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0782	—	None
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.4747	—	Step therapy
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5821	—	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.

Missouri — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2221	—	None
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4653	—	Step therapy
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.7948	—	None
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.4649	—	Step therapy
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6333	—	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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.3149	—	None
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4721	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.6579	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.7055	—	None
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.4721	—	Step therapy

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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2695	—	None
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4638	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.5822	—	None
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6612	—	None
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$0.4638	—	Step therapy

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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.1536	—	None
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4681	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.9916	—	None
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4681	—	Step therapy
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5761	—	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.

Oklahoma — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.3237	—	None
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4734	—	Step therapy
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.6314	—	None
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.4734	—	Step therapy
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6531	—	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.

Colorado — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.3318	—	None
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4612	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.1792	—	None
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6349	—	None
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4612	—	Step therapy

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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.4270	—	None
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4659	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.1855	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.5949	—	None
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4658	—	Step therapy

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 — 5 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$1.2291	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4601	—	Step therapy
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0742	—	None
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4601	—	Step therapy
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.5792	—	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.

Oregon and Washington — 5 plans, 2 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	16%	16%	$1.3118	—	None
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4639	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0066	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6044	—	None
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4639	—	Step therapy

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

Maine and New Hampshire — 4 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4628	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0618	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.6237	—	None
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.4628	—	Step therapy

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

Virginia — 4 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4704	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0164	—	None
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.4688	—	Step therapy
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.5912	—	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 — 4 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.5538	—	Step therapy
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.6603	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$1.9171	—	None
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.5297	—	Step therapy

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

New Mexico — 4 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.4653	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0763	—	None
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.6592	—	None
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	—	$0.4643	—	Step therapy

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

Hawaii — 4 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4603	—	Step therapy
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.4603	—	Step therapy
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.6535	—	Step therapy
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0358	—	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.

Alaska — 4 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4927	—	Step therapy
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.8057	—	None
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.1488	—	None
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.4927	—	Step therapy

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 — 3 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.4656	—	Step therapy
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.0625	—	None
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.4648	—	Step therapy

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, 1 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%	$1.3525	—	None
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4456	—	Step therapy
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$0.6076	—	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.

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%	$0.9801	—	Step therapy

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%	$0.4739	—	Step therapy

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%	$0.9801	—	Step therapy

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%	$0.4739	—	Step therapy

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