Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| C S | Q | Q | C | Q | Q | Q | Q | Q | QP | C | N | N | N | N |
| C S | Q | Q | C | QP | Q | Q | Q | Q | QP | C | N | N | N | N |
| N | N | Q | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q S | Q | N | QPS | QPS | N | C | N | N | N | N |
| C | Q | Q | C | Q | Q S | Q | Q | Q | Q | C | N | N | N | N |
| C | C | C | C | C | C | C | C | C | C | C | N | N | N | N |
| P | P | P | C | C | C | P | C | C | C | P | N | N | N | N |
| N | Q | C | C | Q | Q | Q | Q | N | Q | C | N | N | N | N |
| N | Q | C | C | Q | Q | Q | Q | N | Q | C | N | N | N | N |
| C | Q | Q | C | Q | C | C | C | C | C | C | N | N | N | N |
| P | P | P | P | P | P | P | P | P | P | P | N | N | N | N |
| C | Q | C | C | C | Q | Q | Q | Q | Q | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C S | Q S | Q | C | QP | C | Q S | C | C | C S | C S | N | N | N | N |
| C | Q | Q | C | Q | Q | Q | Q | Q | Q | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | P | N | N | N | P | QP | QP | N | P | N | N | N | N |
| C | N | N | N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | Q S | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q S | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | N | Q | N | C | N | N | N | C | N | N | N | N |
| C | C | Q | N | Q | N | C | N | N | N | C | N | N | N | N |
| C | C | C | N | C | C | C | N | N | N | C | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| C | P | P | P | C | P | P | P | P | P | C | N | N | N | N |
| C | Q | Q | C | Q S | N | Q | N | N | N | C | N | N | N | N |
| C | Q | Q | C | Q S | N | Q | N | N | N | C | N | N | N | N |
| N | N | P | C | QP | QP | QP | QP | QP | N | P | N | N | N | N |
| N | QP | N | N | QP | N | QP | N | N | QP | P | N | N | N | N |
| P | N | N | N | QP | QP | N | N | N | N | P | N | N | N | N |
| C | Q | Q | N | QP | QP | QP | Q S | Q | C | C | N | N | N | N |
| C | C | Q | N | Q | N | C | C | C | N | C | N | N | N | N |
| C | C | C | C | C | C | C | C | C | C | C | N | N | N | N |
| C | C | C | N | C | C | C | C | C | C | C | N | N | N | N |
| C | C | C | C | C | C | C | C | C | C | C | N | N | N | N |
| N | C | Q | C | Q S | N | QP | QPS | QP | N | C | N | N | N | N |
| P | P | P | P | P | P | P | P | P | P | P | N | N | N | N |
| C | Q S | Q | Q | QP | Q | QP | QP | QP | Q | C | N | N | N | N |
| C | Q | C | C | Q | Q | Q | Q | Q | C | C | N | N | N | N |
| P | QP | P | C | QP | QP | QP | QP | QP | QP | P | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | N | P | P | P | P | P | P | P | N | N | N | N |
| C | P | P | C | C | C | C | C | C | C | C | N | N | N | N |
| C | Q | Q | C | Q | Q | Q | Q | Q | C | C | N | N | N | N |
| N | C | N | N | N | C | N | N | N | N | N | N | N | N | N |
| C S | Q S | C | C | Q S | C | P | C | C | N | C S | N | N | N | N |
| N | N | N | N | Q S | N | N | Q | N | N | N | N | N | N | N |
| C | C | Q | C | P | Q | Q | C | C | Q | C | N | N | N | N |
| P | N | P | N | N | QP | N | QP | QP | P | P | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| C | Q | Q | C | Q | Q | Q | Q | Q | Q | C | N | N | N | N |
| C | C | Q | N | Q | Q | Q | C | C | C | C | N | N | N | N |
| C S | C | Q | N | Q | Q | Q | Q | Q | Q | C S | N | N | N | N |
| C | Q | Q | QPS | Q | Q | QP | Q | Q | Q | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q | N | N | C | C | N | N | N | N | N | N |
| C | N | N | N | N | N | N | C | C | N | C | N | N | N | N |
| P | Q S | C | C | QP | Q S | QP | Q | Q | QP | P | N | N | N | N |
| C | C | C | C | Q | N | C | C | C | C | C | N | N | N | N |
| C | N | N | C | N | Q | N | C | C | N | C | N | N | N | N |
| C | QPS | C | C | Q | C | Q | C | C | Q | C | N | N | N | N |
| N | N | C | N | N | Q | N | Q | Q | Q | C | N | N | N | N |
| N | N | C | N | N | C | N | Q | Q | Q | C | N | N | N | N |
| N | C | C | N | N | C | N | Q | Q | Q | C | N | N | N | N |
| N | N | C | N | N | C | N | Q | Q | Q | C | N | N | N | N |
| N | C | C | N | N | C | N | Q | Q | Q | C | N | N | N | N |
| N | QP | C | N | QP | Q | QP | Q | P | Q | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C S | Q | Q | C | QP | Q S | Q | Q | Q | QP | C S | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | P | P | QP | P | P | P | P | P | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | Q | N | Q | Q | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| C | C | C | C | C | C | C | N | N | Q | C | N | N | N | N |
| N | Q S | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | C | C | C | C | C | C | C | C | P | N | N | N | N |
| C | QPS | Q | Q | Q | QP | Q | P | P | Q | C | N | N | N | N |
| C | C | C | N | C | N | C | C | C | C | C | N | N | N | N |
| C | Q | C | C | Q | Q | C | C | C | C | C | N | N | N | N |
| C | N | N | N | N | N | N | C | C | N | C | N | N | N | N |
| C | C | Q | N | Q | Q | Q | C | C | Q | C | N | N | N | N |
| N | N | C | N | Q | N | Q | Q | N | N | C | N | N | N | N |
| C | P | P | C | P | QP | QP | C | C | QP | C | N | N | N | N |
| C | N | C | N | Q | N | Q | Q | Q | N | C | N | N | N | N |
| N | N | C | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | C | C | Q | C | C | C | C | C | N | N | N | N |
| P | N | N | N | N | N | N | N | N | P | P | N | N | N | N |
| C | Q | Q | C | Q | Q | Q | C | C | Q | C | N | N | N | N |
| C | C | Q | C | Q | Q | Q | Q | Q | Q | C | N | N | N | N |
| C | C | N | N | Q | Q | Q | C | N | C | C | N | N | N | N |
| P | P | C | C | P | QP | P | QP | QP | P | P | N | N | N | N |
| C | C | Q | N | Q | N | N | Q | N | N | C | N | N | N | N |
| C | C | C | N | C | N | C | C | C | N | C | N | N | N | N |
| C | C | C | N | C | N | C | C | C | C | C | N | N | N | N |
| C | C | N | C | C | C | C | N | N | N | C | N | N | N | N |
| N | C | N | C | C | C | C | N | N | N | C | N | N | N | N |
| C | C | N | C | C | C | C | N | N | N | C | N | N | N | N |
| N | N | N | N | QP | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| C | C | Q | C | Q | Q | Q | Q | Q | C | C | N | N | N | N |
| P | QP | QP | QP | P | QP | P | QP | QP | P | P | N | N | N | N |
| P | QP | QP | QP | C | QP | P | QP | QP | P | P | N | N | N | N |
| P | QP | QP | QP | N | QP | P | QP | QP | C | P | N | N | N | N |
| C | N | Q | C | Q S | Q S | N | Q | Q | Q | C | N | N | N | N |
| N | N | Q | N | N | N | Q | QP | Q | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | C | Q | Q | N | Q | N | C | C | N | N | N | N |
| N | C | C | C | Q | C | C | C | C | C | N | N | N | N | N |
| N | Q | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | Q | C | Q | Q | C | C | C | Q | P | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | QP | QP | QP | P | QP | QP | P | P | N | N | N | N |
| P | P | P | P | N | P | P | C | C | P | P | N | N | N | N |
| P | QPS | C | N | QP | QP | Q | C S | N | QP | P | N | N | N | N |
| C | N | C | N | C | N | C | C | C | P | C | N | N | N | N |
| C | P | C | N | C | N | P | C | C | P | C | N | N | N | N |
| C | N | C | N | N | N | N | N | N | C | C | N | N | N | N |
| N | N | N | C | N | C | N | N | N | C | C | N | N | N | N |
| P | QP | N | P | N | N | QP | QP | QP | QP | P | N | N | N | N |
| P | N | P | N | N | N | QP | P | P | N | P | N | N | N | N |
| C | N | N | C | N | N | N | N | N | N | C | N | N | N | N |
| C S | Q S | C | C | Q S | N | QP | C | C | Q | C S | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| P | N | C | C | N | QP | N | C S | C | N | P | N | N | N | N |
| P | QP | QP | N | QP | C | P | P | P | P | P | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | N | P | N | QP | QP | QP | QP | QP | P | N | N | N | N |
| N | N | N | N | Q S | N | N | N | N | N | N | N | N | N | N |
| C | Q | C | C | Q | Q | Q | Q | Q | QP | C | N | N | N | N |
| C | Q | Q | C | Q | Q | Q | Q | Q | Q | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q | N | N | N | N | N | C | N | N | N | N |
| C | Q | Q | C | P | Q | Q | QP | Q | Q | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | N | C | C | N | C | C | C | N | C | N | N | N | N |
| C | Q | Q | C | Q | Q | Q | Q | Q | C | C | N | N | N | N |
| C | Q | C | C | Q | Q | Q | Q | Q | C | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | C | C | C | C | C | C | C | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | C | Q | Q | Q | C | C | C | C | N | N | N | N |
| N | C | Q | N | Q | Q | Q | N | N | N | C | N | N | N | N |
| N | C | Q | N | Q | N | Q | C | N | N | C | N | N | N | N |
| C S | C | Q S | C S | N | N | C S | P | P | C S | C S | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | QP | P | QP | P | P | QP | P | P | P | N | N | N | N |
| N | Q | C | N | Q | C | C | C | C | C | C | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-358 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-047 | Cigna Medicare Rx Plan One (PDP) S5617-221 | EnvisionRxPlus Silver (PDP) S7694-070 | First Health Part D Premier (PDP) S5768-016 | Humana Walmart-Preferred Rx Plan (PDP) S5884-136 | SilverScript Basic (PDP) S5601-026 | SmartD Rx Saver (PDP) S0064-013 | United American - Select (PDP) S5755-084 | WellCare Classic (PDP) S5967-150 | Erickson Advantage Guardian (HMO-POS SNP) H5652-003 | Fidelis Secure Comfort (HMO SNP) H2323-005 | Fidelis Secure Comfort Plus (HMO SNP) H2323-006 | Fidelis Secure Freedom (HMO SNP) H2323-011 | Fidelis Secure Independence (HMO SNP) H2323-007 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | QP | N | N | N | N | Q | C | N | N | N | N |
| P | QP | Q | C | Q | Q | N | C | C | Q | P | N | N | N | N |
| C | N | QP | C | N | QP | P | Q | Q | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | N | Q | N | Q | Q | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | C | Q | Q | C | Q | Q | Q | C | N | N | N | N |
| C | QP | Q | C | Q | Q | Q | Q | Q | QP | C | N | N | N | N |
| C | N | C | N | N | N | N | C | C | N | C | N | N | N | N |
| C | Q | N | N | N | Q | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | C | QP | C | C | Q | Q | QP | P | N | N | N | N |