PHENOBARBITAL 64.8 mg Tablet

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	2–4	$3.00	8 of 12 plans
Pennsylvania and West Virginia	12 of 12	2–4	$3.00	10 of 12 plans
North Carolina	12 of 12	2–4	$3.00	8 of 12 plans
Alabama and Tennessee	12 of 12	2–4	$3.00	8 of 12 plans
Michigan	12 of 12	2–4	$3.00	10 of 12 plans
Illinois	12 of 12	2–4	$1.00	8 of 12 plans
Arkansas	12 of 12	2–4	$3.00	10 of 12 plans
Texas	12 of 12	2–4	$1.00	8 of 12 plans
Kansas	12 of 12	2–4	$0.00	7 of 12 plans
California	12 of 12	2–4	$3.00	10 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	2–4	$3.00	9 of 11 plans
South Carolina	11 of 11	2–4	$3.00	8 of 11 plans
Oklahoma	11 of 11	2–4	$1.00	7 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	2–4	$3.00	8 of 11 plans
New Mexico	11 of 11	2–4	$3.00	7 of 11 plans
New York	10 of 10	2–4	$3.00	8 of 10 plans
Delaware, DC and Maryland	10 of 10	2–4	$3.00	8 of 10 plans
Georgia	10 of 10	2–4	$3.00	8 of 10 plans
Florida	10 of 10	2–4	$3.00	6 of 10 plans
Ohio	10 of 10	2–4	$3.00	8 of 10 plans
Indiana and Kentucky	10 of 10	2–4	$3.00	8 of 10 plans
Wisconsin	10 of 10	2–4	$3.00	8 of 10 plans
Missouri	10 of 10	2–4	$3.00	8 of 10 plans
Mississippi	10 of 10	2–4	$3.00	8 of 10 plans
Louisiana	10 of 10	2–4	$3.00	8 of 10 plans
Colorado	10 of 10	2–4	$3.00	8 of 10 plans
Arizona	10 of 10	2–4	$3.00	8 of 10 plans
Nevada	10 of 10	2–4	$3.00	8 of 10 plans
Oregon and Washington	10 of 10	2–4	$3.00	8 of 10 plans
Idaho and Utah	10 of 10	2–4	$3.00	8 of 10 plans
Maine and New Hampshire	9 of 9	2–4	$3.00	7 of 9 plans
Virginia	9 of 9	2–4	$3.00	7 of 9 plans
Alaska	9 of 9	2–4	$3.00	7 of 9 plans
Hawaii	8 of 8	2–4	$3.00	6 of 8 plans
Puerto Rico	3 of 3	2–4	—	2 of 3 plans
American Samoa	1 of 1	2	—	none
Guam	1 of 1	2	—	none
Northern Mariana Islands	1 of 1	2	—	none
U.S. Virgin Islands	1 of 1	2	—	none

New Jersey — 12 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1500	$1.359 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0747	—	Prior authorization
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1303	—	Prior authorization
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.1500	$1.359 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.1247	$1.5012 units	Prior authorization Quantity limit 12 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$0.9439	—	None
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2749	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.1277	$1.5312 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1500	$1.359 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3320	—	None
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	2Generic	$6.00	$9.00	$0.9439	—	None

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

Pennsylvania and West Virginia — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1513	$1.369 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0804	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1348	—	Prior authorization
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1513	$1.369 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.2281	—	None
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1300	$1.5612 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1333	$1.6012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2896	—	None
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1513	$1.369 units	Quantity limit 9 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.1080	—	Prior authorization
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.1074	—	Prior authorization

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

North Carolina — 12 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0859	—	Prior authorization
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1371	—	Prior authorization
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1540	$1.399 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1540	$1.399 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2075	—	None
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1315	$1.5812 units	Prior authorization Quantity limit 12 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.9443	—	None
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.1341	$1.6112 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1540	$1.399 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2620	—	None
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	2Generic	$6.00	$18.00	$0.9443	—	None

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

Alabama and Tennessee — 12 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1532	$1.389 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0827	—	Prior authorization
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1325	—	Prior authorization
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1532	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2122	—	None
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$0.9483	—	None
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1267	$1.5212 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.1287	$1.5412 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1532	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2588	—	None
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	2Generic	$12.00	$24.00	$0.9483	—	None

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

Michigan — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0805	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1501	$1.359 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	3Preferred Brand	20%	15%	$0.1501	$1.359 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1255	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	30%	$0.1226	$1.4712 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2224	—	None
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1212	$1.4512 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2706	—	None
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.2332	$2.8012 units	Prior authorization Quantity limit 36 per 90 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1501	$1.359 units	Quantity limit 9 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$0.2332	$2.8012 units	Prior authorization Quantity limit 36 per 90 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0740	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1550	$1.409 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	3Preferred Brand	20%	15%	$0.1550	$1.409 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1470	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.2260	—	None
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1395	$1.6712 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$0.9523	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2410	—	None
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.1416	$1.7012 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1550	$1.409 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.9438	—	None

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

Arkansas — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.1024	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1553	$1.409 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	3Preferred Brand	20%	15%	$0.1553	$1.409 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	26%	26%	$0.1183	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1159	$1.3912 units	Prior authorization Quantity limit 12 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.0924	$1.1112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1158	$1.3912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2160	—	None
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1528	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1553	$1.409 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	2Generic	$10.00	$54.00	$0.2608	—	None
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	3Preferred Brand	20%	20%	$0.0924	$1.1112 units	Prior authorization Quantity limit 12 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0773	—	Prior authorization
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1294	—	Prior authorization
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1524	$1.379 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1524	$1.379 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1253	$1.5012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.2115	—	None
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1529	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$0.9354	—	None
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1269	$1.5212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2286	—	None
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1524	$1.379 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.9262	—	None

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

Kansas — 12 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$0.00	$0.00	$0.9583	—	None
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	40%	40%	$0.9579	—	None
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1349	$1.6212 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0940	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	26%	26%	$0.1405	—	Prior authorization
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1602	$1.449 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1602	$1.449 units	Quantity limit 9 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	2Generic	$0.00	$0.00	$0.9579	—	None
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.2412	—	None
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1602	$1.449 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2707	—	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 — 12 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1374	$1.6512 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0730	—	Prior authorization
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1399	—	Prior authorization
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1328	$1.5912 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1525	$1.379 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.2309	—	None
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1525	$1.379 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2985	—	None
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1525	$1.379 units	Quantity limit 9 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	4Non-Preferred Drug	49%	49%	$0.1296	—	Prior authorization
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.1296	—	Prior authorization

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

Connecticut, Massachusetts, Rhode Island and Vermont — 11 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1524	$1.379 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0727	—	Prior authorization
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	17%	17%	$0.0918	$1.1012 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1419	—	Prior authorization
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2590	—	None
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1524	$1.379 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	$0.1524	$1.379 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1416	$1.7012 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3160	—	None
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	3Preferred Brand	$30.00	$60.00	$0.0918	$1.1012 units	Prior authorization Quantity limit 12 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0803	—	Prior authorization
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1325	—	Prior authorization
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1522	$1.379 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.1522	$1.379 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1268	$1.5212 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2117	—	None
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2810	—	None
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$0.3829	—	None
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1522	$1.379 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1302	$1.5612 units	Prior authorization Quantity limit 12 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, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1561	$1.409 units	Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	40%	40%	$0.9329	—	None
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0959	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	26%	26%	$0.1318	—	Prior authorization
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1561	$1.409 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1270	$1.5212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.2132	—	None
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1561	$1.409 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2524	—	None
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.1277	$1.5312 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.9304	—	None

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

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1544	$1.399 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	—	$0.2251	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0951	—	Prior authorization
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1335	—	Prior authorization
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1544	$1.399 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1531	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1177	$1.4112 units	Prior authorization Quantity limit 12 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$0.9475	—	None
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1544	$1.399 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1184	$1.4212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2536	—	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 Mexico — 11 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0906	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1529	$1.389 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1394	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1341	$1.6112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	43%	—	$0.2507	—	None
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1529	$1.389 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	$0.1529	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2654	—	None
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1525	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	2Generic	$4.00	$12.00	$0.9109	—	None
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.9231	—	None

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

New York — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1301	$1.5612 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0767	—	Prior authorization
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1330	—	Prior authorization
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1278	$1.5312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.2352	—	None
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1495	$1.359 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$0.1495	$1.359 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2860	—	None
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1495	$1.359 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1532	$1.389 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1532	$1.389 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0719	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1389	—	Prior authorization
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1354	$1.6212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2294	—	None
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1326	$1.5912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2632	—	None
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1532	$1.389 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0832	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1538	$1.389 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1309	—	Prior authorization
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1538	$1.389 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1270	$1.5212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2129	—	None
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1531	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1538	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2586	—	None
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1289	$1.5512 units	Prior authorization Quantity limit 12 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, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0764	—	Prior authorization
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1364	—	Prior authorization
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1537	$1.389 units	Quantity limit 9 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1537	$1.389 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.9544	—	None
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2156	—	None
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1537	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2427	—	None
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.9544	—	None

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

Ohio — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1534	$1.389 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0799	—	Prior authorization
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1356	—	Prior authorization
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1534	$1.389 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1325	$1.5912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$0.2184	—	None
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1529	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1347	$1.6212 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1534	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2671	—	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 — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1541	$1.399 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0799	—	Prior authorization
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1367	—	Prior authorization
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1541	$1.399 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1327	$1.5912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$0.2092	—	None
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1354	$1.6212 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1541	$1.399 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2649	—	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 — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0836	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1535	$1.389 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	3Preferred Brand	20%	15%	$0.1535	$1.389 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	26%	26%	$0.1310	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	30%	$0.1256	$1.5112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	33%	—	$0.2088	—	None
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.1529	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1250	$1.5012 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1535	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2377	—	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 — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0904	—	Prior authorization
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	26%	26%	$0.1344	—	Prior authorization
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1560	$1.409 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1560	$1.409 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1275	$1.5312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	4Non-Preferred Drug	39%	—	$0.2362	—	None
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1290	$1.5512 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1531	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2752	—	None
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1560	$1.409 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0843	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1500	$1.359 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1189	—	Prior authorization
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1500	$1.359 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1160	$1.3912 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1152	$1.3812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	4Non-Preferred Drug	37%	—	$0.2154	—	None
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1500	$1.359 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2682	—	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.

Louisiana — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1551	$1.409 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0913	—	Prior authorization
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1315	—	Prior authorization
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1551	$1.409 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$0.2099	—	None
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1288	$1.5512 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1270	$1.5212 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1551	$1.409 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2574	—	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 — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0820	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1559	$1.409 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1342	—	Prior authorization
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1559	$1.409 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1341	$1.6112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1337	$1.6012 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2165	—	None
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1559	$1.409 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2311	—	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.

Arizona — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0821	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	23%	18%	$0.1584	$1.439 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	32%	$0.1503	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1470	$1.7612 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1584	$1.439 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2125	—	None
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1444	$1.7312 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1536	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2770	—	None
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1584	$1.439 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, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1540	$1.399 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0733	—	Prior authorization
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1409	—	Prior authorization
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1540	$1.399 units	Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1345	$1.6112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2083	—	None
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1373	$1.6512 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2459	—	None
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1540	$1.399 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.

Oregon and Washington — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0797	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1538	$1.389 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1328	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	30%	$0.1323	$1.5912 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1538	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2184	—	None
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	3Preferred Brand	16%	16%	$0.1311	$1.5712 units	Prior authorization Quantity limit 12 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1529	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1538	$1.389 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2410	—	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 — 10 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1547	$1.399 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0857	—	Prior authorization
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1547	$1.399 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1251	—	Prior authorization
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1235	$1.4812 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.2101	—	None
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1547	$1.399 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.1240	$1.4912 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2415	—	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.

Maine and New Hampshire — 9 plans, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0788	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1504	$1.359 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	27%	27%	$0.1284	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	30%	30%	$0.1260	$1.5112 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1504	$1.359 units	Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.2242	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1528	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2320	—	None
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1504	$1.359 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, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	2Generic	$3.00	$9.00	$0.0852	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	25%	20%	$0.1577	$1.429 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	3Preferred Brand	20%	15%	$0.1577	$1.429 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	31%	31%	$0.1418	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2078	—	None
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1531	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1577	$1.429 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2664	—	None
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.1408	$1.6912 units	Prior authorization Quantity limit 12 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, 7 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	24%	19%	$0.1547	$1.399 units	Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	28%	28%	$0.1367	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	29%	29%	$0.1357	$1.6312 units	Prior authorization Quantity limit 12 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1547	$1.399 units	Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0981	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2877	—	None
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$0.1530	$1.8412 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3043	—	None
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1547	$1.399 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.

Hawaii — 8 plans, 6 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 · $0 with full Extra Help	4Non-Preferred Drug	38%	—	$0.2076	—	None
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible · $0 with full Extra Help	3Preferred Brand	23%	18%	$0.1522	$1.379 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1527	$1.8312 units	Prior authorization Quantity limit 12 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0864	—	Prior authorization
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	35%	35%	$0.1388	—	Prior authorization
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1522	$1.379 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	$0.1522	$1.379 units	Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.3096	—	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.

Puerto Rico — 3 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	17%	17%	$0.1258	$1.5112 units	Prior authorization Quantity limit 12 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$0.1258	$1.5112 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	2Generic	25%	25%	$0.2423	—	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

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 · $0 with full Extra Help	2Generic	25%	25%	$0.3304	—	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.

Guam — 1 plan

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 · $0 with full Extra Help	2Generic	25%	25%	$0.3304	—	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.

Northern Mariana Islands — 1 plan

Maximum premiumMaximum deductiblePlanSort by

Showing 1 of 1 plan

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	2Generic	25%	25%	$0.2978	—	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.

U.S. Virgin Islands — 1 plan

Maximum premiumMaximum deductiblePlanSort by

Showing 1 of 1 plan

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	2Generic	25%	25%	$0.2978	—	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.

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