Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| Q | Q | C | Q | QP | Q | Q | Q | Q | Q | Q | QP | Q S | C | Q | Q | C | C | P | C | C |
| Q | Q | C | Q | QP | Q | Q | Q | Q | Q | Q | QP | Q S | C | Q | Q | C | C | C | C | C |
| N | Q | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C S | N | N |
| N | N | N | QPS | Q S | QPS | Q | Q | N | QPS | QPS | N | Q | C | QPS | Q S | C | C | C | C | C |
| Q | Q | C | Q | Q | Q | Q | Q S | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | C | C |
| C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C |
| P | P | C | C | C | C | C | C | P | C | C | C | P | P | C | P | P | P | C | P | P |
| Q | C | C | Q | N | N | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | Q | Q | C | C | C |
| Q | C | C | Q | N | N | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | Q | Q | C | C | C |
| Q | Q | C | C | Q | C | Q | C | C | C | C | C | Q | C | C | C | C | C | C | C | C |
| P | P | P | P | P | P | QP | P | P | P | P | P | P | P | P | P | P | P | P | P | P |
| Q | C | C | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C | Q | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C | N | N |
| Q S | Q | C | C | QP | C | Q | C | Q S | C | C | C S | Q | C S | C | Q S | C S | C S | C | C S | C S |
| Q | Q | C | Q | Q | Q | C | Q | Q | Q | Q | Q | C | C | Q | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | N | QP | N | QP | P | N | P | QP | QP | N | QP | P | QP | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | Q | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| C | Q | N | N | Q | N | C | N | C | N | N | N | C | C | N | N | C | C | C | C | C |
| C | Q | N | N | Q | N | C | N | C | N | N | N | C | C | N | N | C | C | C | C | C |
| C | C | N | N | C | N | C | C | C | N | N | N | C | C | N | N | C | C | C | C | C |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| P | P | P | P | C | P | C | P | P | P | P | P | P | P | P | P | P | P | P | C | C |
| Q | Q | C | Q | Q | N | N | N | Q | N | Q | N | C S | C | Q | C | C | C | C | C | C |
| Q | Q | C | Q | Q | N | N | N | Q | N | Q | N | C S | C | Q | C | C | C | C | C | C |
| N | P | C | QP | QP | QP | N | QP | QP | QP | QP | N | C S | QP | QP | P | QP | QP | P | P | P |
| QP | N | N | N | QP | N | N | N | QP | N | N | QP | QP | QP | N | N | QP | QP | P | P | P |
| N | N | N | N | QP | N | N | QP | N | N | N | N | N | P | N | N | P | P | P | P | P |
| Q | Q | N | Q | QP | Q | N | QP | QP | Q S | Q | C | Q S | P | Q | Q | P | P | C S | C | C |
| C | Q | N | C | Q | C | N | N | C | C | C | N | C | C | C | N | C | C | C | C | C |
| C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C | C |
| C | C | N | C | C | 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 | C | C | C | C | C | C | P | C | C | C | C | C |
| C | Q | C | QP | Q S | QP | Q S | N | QP | QPS | QP | N | Q S | P | QP | C S | P | P | C S | C | C |
| P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P |
| Q S | Q | Q | QP | QP | QP | QP | Q | QP | QP | QP | Q | QP | QP | QP | Q | QP | QP | C | C | C |
| Q | C | C | Q | Q | Q | C | Q | Q | Q | Q | C | C | Q | Q | Q | Q | Q | C | C | C |
| QP | P | C | QP | QP | QP | QP | QP | QP | QP | QP | QP | C | QP | QP | QP | QP | QP | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| N | P | N | P | P | P | P | P | P | P | P | P | P | P | P | P | P | P | C | P | P |
| P | P | C | C | C | C | C | C | C | C | C | C | P | C | C | P | C | C | C | C | C |
| Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C | Q | C | Q | Q | C | C | C | C | C |
| C | N | N | N | N | N | N | C | N | N | N | N | N | C | N | N | C | C | C | N | N |
| Q S | C | C | C | Q S | C | C | C | P | C | C | N | P | P | C | Q | P | P | C | C S | C S |
| N | N | N | Q | Q S | N | N | N | N | Q | Q | N | N | C | Q | Q | C | C | C | N | N |
| C | Q | C | C | P | C | Q | Q | Q | C | C | Q | Q | C | C | Q | C | C | Q | C | C |
| N | P | N | QP | N | QP | N | QP | N | QP | QP | P | QP | P | QP | QP | P | P | P | P | P |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| Q | Q | C | Q | Q | Q | N | Q | Q | Q | Q | Q | C | Q | Q | Q | Q | Q | C | C | C |
| C | Q | N | C | Q | C | N | Q | Q | C | C | C | Q | C | C | N | C | C | C | C | C |
| C | Q | N | Q | Q | Q | Q | Q | Q | Q | Q | Q | QP | C | Q | C | C | C | C | C S | C S |
| Q | Q | QPS | Q | Q | Q | Q | Q | QP | Q | Q | Q | QP | QP | Q | QP | QP | QP | C | C | 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 | C | Q | C | N | N | N | C | C | N | C S | N | C | C | N | N | C | N | N |
| N | N | N | C | N | C | N | N | N | C | C | N | N | C | C | N | C | C | C | C | C |
| Q S | C | C | Q | QP | Q | QP | Q S | QP | Q | Q | QP | Q | P | Q | QP | P | P | P | P | P |
| C | C | C | C | Q | C | Q S | N | C | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | C | C | N | C | N | Q | N | C | C | N | N | C | C | Q | C | C | Q | C | C |
| QPS | C | C | C | QP | C | Q | C | Q | C | C | Q | Q | C | C | C | C | C | P | C | C |
| N | C | N | Q | N | Q | C | Q | N | Q | Q | Q | Q | C | Q | N | C | C | P | C | C |
| N | C | N | Q | N | Q | C | C | N | Q | Q | Q | Q | C | Q | N | C | C | C | C | C |
| C | C | N | Q | N | Q | C | C | N | Q | Q | Q | Q | C | Q | N | C | C | C | C | C |
| N | C | N | Q | N | Q | C | C | N | Q | Q | Q | Q | C | Q | N | C | C | C | C | C |
| C | C | N | Q | N | Q | C | C | N | Q | Q | Q | Q | C | Q | N | C | C | C | C | C |
| QP | C | N | P | QP | P | N | Q | QP | Q | P | Q | Q | P | P | Q | P | P | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | P | N | N | P | P | C | N | N |
| Q | Q | C | Q | QP | Q | Q S | Q S | Q | Q | Q | QP | Q S | C | Q | Q | C | C | C | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | P | P | P | P | P | QP | QP | P | P | P | P | Q | 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 | N |
| Q | N | N | Q | Q | Q | N | Q | N | Q | Q | N | C | C | Q | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| C | C | C | N | C | N | C | C | C | N | N | Q | Q S | C | N | C | C | C | C | C | C |
| Q S | N | N | N | N | N | N | N | N | N | N | N | C | C | N | N | C | C | C | N | N |
| P | C | C | C | C | C | C | C | C | C | C | C | P | C | C | C | C | C | C | P | P |
| QPS | Q | Q | P | Q | P | QP | QP | Q | P | P | Q | C | P | P | QP | P | P | C | C | C |
| C | C | N | C | C | C | N | N | C | C | C | C | C | C | C | N | C | C | C | C | C |
| Q | C | C | C | Q S | C | Q | Q | C | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | N | C | N | C | Q | N | N | C | C | N | Q | C | C | N | C | C | Q | C | C |
| C | Q | N | C | Q | C | Q | Q | Q | C | N | Q | Q | Q | C | C | Q | Q | C | C | C |
| N | C | N | Q | Q | N | N | N | Q | Q | Q | N | N | Q | Q | Q S | Q | Q | C | C | C |
| P | P | C | C | P | C | QP | QP | QP | C | C | QP | Q | P | C | C | P | P | P | C | C |
| N | C | N | Q | Q | Q | N | N | Q | Q | Q | N | C | C | Q | N | C | C | C | C | C |
| N | C | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| C | C | C | C | C | C | C | Q | C | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | C | N | N | N | N | P | P | P | N | P | P | P | C | P | P |
| Q | Q | C | C | Q | C | Q | Q | Q | C | C | Q | Q S | Q | C | Q | Q | Q | C | C | C |
| C | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | Q | C | C | C | C | C | C |
| C | N | N | C | Q | N | Q | Q | Q | C | C | C | Q | Q | C | N | Q | Q | C | C | C |
| P | C | C | QP | P | QP | P | QP | P | QP | QP | P | C | P | QP | P | P | P | P | P | P |
| C | Q | N | Q | Q | N | Q | N | N | Q | Q | N | N | Q | Q | Q S | Q | Q | C S | C | C |
| C | C | N | C | C | C | C | N | C | C | C | N | N | C | C | PS | C | C | C | C | C |
| C | C | N | C | C | C | N | N | C | C | C | C | C | C | C | N | C | C | C | C | C |
| C | N | C | Q | C | N | N | C | C | N | Q | N | Q | C | Q | C | C | C | P | C | C |
| C | N | C | Q | C | N | N | C | C | N | Q | N | Q | C | Q | C | C | C | C | C | C |
| C | N | C | Q | C | N | N | C | C | N | Q | N | Q | C | Q | C | C | C | C | C | C |
| N | N | N | N | QP | N | N | N | N | N | N | N | QP | P | N | N | P | P | P | N | N |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| C | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C | C | Q | Q | Q | Q | Q | C S | C | C |
| QP | QP | QP | QP | P | QP | Q | QP | P | QP | QP | P | P | P | QP | QP | P | P | C | P | P |
| QP | QP | QP | QP | C | QP | Q | QP | P | QP | QP | P | P | P | QP | QP | P | P | C | P | P |
| QP | QP | QP | QP | N | QP | Q | QP | P | QP | QP | C | P | P | QP | QP | P | P | C | P | P |
| N | Q | C | Q | Q S | Q | N | Q S | N | Q | Q | Q | N | Q | Q | C | Q | Q | C | C | C |
| N | Q | N | Q | N | Q | QP | N | Q | QP | Q | N | Q | Q | Q | Q S | 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 | Q | C | Q | Q | N | Q | Q | N | Q | Q | C | C | Q | Q | Q | Q | Q | C | C | C |
| C | C | C | C | Q | C | C | C | C | C | C | C | C S | C | C | C | C | C | C | N | N |
| Q | N | N | N | N | N | Q | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| QP | Q | C | C | Q | C | N | Q | C | C | C | Q | QP | C | C | Q | C | C | C | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C S | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C S | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C S | N | N |
| QP | P | QP | QP | QP | QP | P | QP | P | QP | QP | P | QP | P | QP | QP | P | P | P | P | P |
| P | P | P | C | N | C | P | P | P | C | C | P | P | P | C | P | P | P | P | P | P |
| QPS | C | N | C S | QP | N | Q S | QP | Q | C S | C S | QP | QP | C | C S | N | C | C | P | P | P |
| N | C | N | C | C | C | C | N | C | C | C | P | P | C | C | N | C | C | C | C | C |
| P | C | N | C | C | C | C | N | P | C | C | P | P | C | C | P | C | C | C | C | C |
| N | C | N | N | N | N | C | N | N | N | N | C | N | N | N | N | N | N | C | C | C |
| N | N | C | N | N | N | N | C | N | N | N | C | C | Q | N | N | Q | Q | C S | C | C |
| QP | N | P | QP | N | QP | N | N | QP | QP | QP | QP | N | P | QP | C | P | P | P | P | P |
| N | P | N | P | N | P | N | N | QP | P | P | N | N | P | P | N | P | P | P | P | P |
| N | N | C | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C | C | C |
| Q S | C | C | C | Q S | C | Q S | N | QP | C | C | Q | Q | P | C | C | P | P | C | C S | C S |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| N | C | C | C | N | C | P | QP | N | C S | C | N | Q | N | C | C | N | N | P | P | P |
| QP | QP | N | P | QP | P | P | C | P | P | P | P | QP | P | P | Q | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| QP | N | P | QP | N | QP | QP | QP | QP | QP | QP | QP | QP | P | QP | QP | P | P | P | P | P |
| N | N | N | N | Q S | N | N | N | N | N | N | N | Q | Q | N | N | Q | Q | C | N | N |
| Q | C | C | Q | Q | Q | C | Q | Q | Q | Q | QP | Q | P | Q | Q | P | P | P | C | C |
| Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | Q | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | C | Q | N | N | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| N | N | N | N | Q | N | N | N | N | N | N | N | C | C | N | N | C | C | C | C | C |
| Q | Q | C | Q | P | Q | Q | Q | Q | QP | Q | Q | Q | Q | Q | C | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N |
| C | N | C | C | C | C | N | N | C | C | C | N | C | C | C | C | C | C | C | C | C |
| Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C | C | C | Q | Q | C | C | C | C | C |
| Q | C | C | Q | Q | Q | C | Q | Q | Q | Q | C | C | C | Q | 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 | N | N |
| C | C | C | C | C | C | C | C | C | C | 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 | N | N |
| C | Q | C | C | Q | C | Q | Q | Q | C | C | C | N | Q | C | Q | Q | Q | C | C | C |
| C | Q | N | N | Q | N | N | Q | Q | N | N | N | C | C | N | C | C | C | C | C | C |
| C | Q | N | C | Q | N | C | N | Q | C | C | N | C | C | C | N | C | C | C | C | C |
| C | Q S | C S | P | N | P | C S | N | C S | P | P | C S | Q S | C S | P | N | C S | C S | C | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| P | QP | P | P | QP | P | C | P | P | QP | P | P | P | P | P | P | P | P | C | P | P |
| Q | C | N | C | Q | C | Q S | C | C | C | C | C | C S | C | C | N | C | C | C | C | C |
| Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-037 | Cigna Medicare Rx Plan One (PDP) S5617-013 | EnvisionRxPlus Silver (PDP) S7694-003 | Express Scripts Medicare - Value (PDP) S5983-004 | First Health Part D Essentials (PDP) S5569-007 | First United American - Select (PDP) S5580-006 | HealthSpring Prescription Drug Plan -Reg 3 (PDP) S5932-004 | Humana Walmart-Preferred Rx Plan (PDP) S5552-004 | SilverScript Basic (PDP) S5601-006 | SmartD Rx Saver (PDP) S0064-003 | SmartSaver Rx PDP (PDP) S1140-001 | WellCare Classic (PDP) S5967-140 | Access Medicare Silver (HMO SNP) H4866-006 | ArchCare - Inst and IE SNP - All Counties (HMO SNP) H1777-007 | CenterLight Direct Complete Plan (HMO SNP) H5989-002 | Elderplan Advantage For Nursing Home Residents (HMO SNP) H3347-003 | Fidelis Long Term Care Advantage (HMO SNP) H3328-018 | Healthfirst AssuredCare (HMO SNP) H3359-035 | Independent Health Medicare Family Choice (HMO SNP) H3362-020 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-002 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3379-022 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| Q | Q | N | N | N | N | N | N | N | N | N | Q | N | C | N | C S | C | C | C | C | C |
| QP | Q | C | C | Q | C | QP | Q | N | C | C | Q | QP | C | C | C | C | C | C | P | P |
| N | QP | C | Q | N | Q | QP | QP | P | Q | Q | N | QP | P | Q | C | P | P | Q | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | P | N | N | P | P | P | N | N |
| N | C | N | Q | Q | N | N | N | Q | Q | N | N | N | Q | Q | Q | Q | Q | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | Q | N | N | Q | Q | C S | N | N |
| Q | Q | C | Q | Q | Q | Q | Q | C | Q | Q | Q | C | C | Q | Q S | C | C | C | C | C |
| QP | Q | C | Q | Q | Q | N | Q | Q | Q | Q | QP | Q | C | Q | C | C | C | C | C | C |
| N | C | N | C | N | C | C | N | N | C | C | N | C | C | C | N | C | C | C | C | C |
| Q | N | N | N | N | N | C | Q | N | N | N | N | Q | C | N | C | C | C | P | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | C | N | N | C | C | C | N | N |
| QP | P | C | Q | QP | Q | P | C | C | Q | Q | QP | C | C | Q | P | C | C | P | P | P |