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) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| C S | C | Q | Q | Q | Q | QP | C |
| C S | C | QP | Q | Q | Q | QP | C |
| N | N | N | N | N | N | N | N |
| N | N | Q S | Q | N | QPS | N | C |
| C | C | Q | Q S | Q | Q | Q | C |
| C | C | C | C | C | C | C | C |
| P | C | C | C | P | C | C | P |
| N | C | Q | Q | Q | N | Q | C |
| N | C | Q | Q | Q | N | Q | C |
| C | C | Q | C | C | C | C | C |
| P | P | P | P | P | P | P | P |
| C | C | C | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C S | C | QP | C | Q S | C | C S | C S |
| C | C | Q | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N |
| P | N | N | N | P | QP | N | P |
| C | N | N | N | N | N | N | C |
| N | N | Q S | N | N | N | N | N |
| N | N | Q S | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | N | Q | N | C | N | N | C |
| C | N | Q | N | C | N | N | C |
| C | N | C | C | C | N | N | C |
| AARP MedicareRx Saver Plus (PDP) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| C | P | C | P | P | P | P | C |
| C | C | Q S | N | Q | N | N | C |
| C | C | Q S | N | Q | N | N | C |
| N | C | QP | QP | QP | QP | N | P |
| N | N | QP | N | QP | N | QP | P |
| P | N | QP | QP | N | N | N | P |
| C | N | QP | QP | QP | Q | C | C |
| C | N | Q | N | C | C | N | C |
| C | C | C | C | C | C | C | C |
| C | N | C | C | C | C | C | C |
| C | C | C | C | C | C | C | C |
| N | C | Q S | N | QP | QP | N | C |
| P | P | P | P | P | P | P | P |
| C | Q | QP | Q | QP | QP | Q | C |
| C | C | Q | Q | Q | Q | C | C |
| P | C | QP | QP | QP | QP | QP | P |
| N | N | N | N | N | N | N | N |
| P | N | P | P | P | P | P | P |
| C | C | C | C | C | C | C | C |
| C | C | Q | Q | Q | Q | C | C |
| N | N | N | C | N | N | N | N |
| C S | C | Q S | C | P | C | N | C S |
| N | N | Q S | N | N | N | N | N |
| C | C | P | Q | Q | C | Q | C |
| P | N | N | QP | N | QP | P | P |
| AARP MedicareRx Saver Plus (PDP) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| C | C | Q | Q | Q | Q | Q | C |
| C | N | Q | Q | Q | C | C | C |
| C S | N | Q | Q | Q | Q | Q | C S |
| C | QPS | Q | Q | QP | Q | Q | C |
| N | N | N | N | N | N | N | N |
| N | N | Q | N | N | C | N | N |
| C | N | N | N | N | C | N | C |
| P | C | QP | Q S | QP | Q | QP | P |
| C | C | Q | N | C | C | C | C |
| C | C | N | Q | N | C | N | C |
| C | C | Q | C | Q | C | Q | C |
| N | N | N | Q | N | Q | Q | C |
| N | N | N | C | N | Q | Q | C |
| N | N | N | C | N | Q | Q | C |
| N | N | N | C | N | Q | Q | C |
| N | N | N | C | N | Q | Q | C |
| N | N | QP | Q | QP | P | Q | C |
| N | N | N | N | N | N | N | N |
| C S | C | QP | Q S | Q | Q | QP | C S |
| N | N | N | N | N | N | N | N |
| P | P | P | QP | P | P | P | P |
| N | N | N | N | N | N | N | N |
| N | N | Q | Q | N | Q | N | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| C | C | C | C | C | N | Q | C |
| N | N | N | N | N | N | N | N |
| P | C | C | C | C | C | C | P |
| C | Q | Q | QP | Q | P | Q | C |
| C | N | C | N | C | C | C | C |
| C | C | Q | Q | C | C | C | C |
| C | N | N | N | N | C | N | C |
| C | N | Q | Q | Q | C | Q | C |
| N | N | Q | N | Q | N | N | C |
| C | C | P | QP | QP | C | QP | C |
| C | N | Q | N | Q | Q | N | C |
| N | N | N | N | N | N | N | N |
| C | C | C | Q | C | C | C | C |
| P | N | N | N | N | N | P | P |
| C | C | Q | Q | Q | C | Q | C |
| C | C | Q | Q | Q | Q | Q | C |
| C | N | Q | Q | Q | N | C | C |
| P | C | P | QP | P | QP | P | P |
| C | N | Q | N | N | N | N | C |
| C | N | C | N | C | C | N | C |
| C | N | C | N | C | C | C | C |
| C | C | C | C | C | N | N | C |
| N | C | C | C | C | N | N | C |
| C | C | C | C | C | N | N | C |
| N | N | QP | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| C | C | Q | Q | Q | Q | C | C |
| P | QP | P | QP | P | QP | P | P |
| P | QP | C | QP | P | QP | P | P |
| P | QP | N | QP | P | QP | C | P |
| C | C | Q S | Q S | N | Q | Q | C |
| N | N | N | N | Q | Q | N | N |
| N | N | N | N | N | N | N | N |
| C | C | Q | Q | N | N | C | C |
| N | C | Q | C | C | C | C | N |
| N | N | N | N | N | N | N | N |
| P | C | Q | Q | 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 |
| P | QP | QP | QP | P | QP | P | P |
| P | P | N | P | P | C | P | P |
| P | N | QP | QP | Q | N | QP | P |
| C | N | C | N | C | C | P | C |
| C | N | C | N | P | C | P | C |
| C | N | N | N | N | N | C | C |
| N | C | N | C | N | N | C | C |
| P | P | N | N | QP | QP | QP | P |
| P | N | N | N | QP | P | N | P |
| C | C | N | N | N | N | N | C |
| C S | C | Q S | N | QP | C | Q | C S |
| AARP MedicareRx Saver Plus (PDP) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| P | C | N | QP | N | C | N | P |
| P | N | QP | C | P | P | P | P |
| N | N | N | N | N | N | N | N |
| P | P | N | QP | QP | QP | QP | P |
| N | N | Q S | N | N | N | N | N |
| C | C | Q | Q | Q | Q | QP | C |
| C | C | Q | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | C |
| N | N | N | N | N | N | N | N |
| N | N | Q | N | N | N | N | C |
| C | C | P | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N |
| C | C | C | N | C | C | N | C |
| C | C | Q | Q | Q | Q | C | C |
| C | C | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N |
| C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N |
| C | C | Q | Q | Q | C | C | C |
| N | N | Q | Q | Q | N | N | C |
| N | N | Q | N | Q | N | N | C |
| C S | C S | N | N | C S | P | C S | C S |
| N | N | N | N | N | N | N | N |
| P | P | QP | P | P | P | P | P |
| N | N | Q | C | C | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-371 | EnvisionRxPlus Silver (PDP) S7694-026 | First Health Part D Premier (PDP) S5768-048 | Humana Walmart-Preferred Rx Plan (PDP) S5884-110 | SilverScript Basic (PDP) S5601-052 | United American - Select (PDP) S5755-097 | WellCare Classic (PDP) S5967-163 | UnitedHealthcare Nursing Home Plan (PPO SNP) H3209-001 |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | N | QP | N | N | N | Q | C |
| P | C | Q | Q | N | C | Q | P |
| C | C | N | QP | P | Q | N | C |
| N | N | N | N | N | N | N | N |
| N | N | Q | N | Q | N | N | N |
| N | N | N | N | N | N | N | N |
| C | C | Q | Q | C | Q | Q | C |
| C | C | Q | Q | Q | Q | QP | C |
| C | N | N | N | N | C | N | C |
| C | N | N | Q | N | N | N | C |
| N | N | N | N | N | N | N | N |
| P | C | QP | C | C | Q | QP | P |