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) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| C S | Q | Q | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| C S | Q | Q | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| N | N | Q | N | N | N | N | N | N | N | N | N | N |
| N | N | C | N | Q | N | N | QPS | Q S | Q S | Q S | Q S | C |
| C | Q | Q | N | Q S | Q | N | Q | Q | Q | Q | Q | C |
| C | C | C | C | P | C | N | C | C | C | C | C | C |
| P | P | P | C | C | P | N | C | P | P | P | P | P |
| N | Q | C | C | Q | Q | N | N | Q | Q | Q | Q | C |
| N | Q | C | C | Q | Q | N | N | Q | Q | Q | Q | C |
| C | Q | Q | C | C | C | N | C | Q | Q | Q | Q | C |
| P | P | P | P | P | P | N | P | P | P | P | P | P |
| C | Q | C | C | Q | Q | N | 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 | N | N | N | N | N |
| C | Q | Q | C | C | Q S | N | C | Q | Q | Q | Q | C |
| C | Q | Q | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| C | N | C | C | N | N | N | N | C | C | C | C | C |
| P | P | P | N | N | P | N | QP | QP | QP | QP | QP | P |
| C | N | N | N | N | N | N | N | 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 | Q | Q | Q | Q | N |
| C | C | Q | N | N | C | N | N | C | C | C | C | C |
| C | C | Q | N | N | C | N | N | C | C | C | C | C |
| C | C | C | N | C | C | N | N | C | C | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| C | P | C | P | P | P | N | P | C | C | C | C | C |
| C | Q | Q | C | N | Q | N | N | Q | Q | Q | Q | C |
| C | Q | Q | C | N | Q | N | N | Q | Q | Q | Q | C |
| N | N | P | C | QP | QP | N | QP | Q | Q | Q | Q | P |
| N | QP | P | N | N | QP | N | N | N | N | N | N | P |
| P | N | N | N | QP | N | N | N | QP | QP | QP | QP | P |
| C | Q | Q | N | Q S | QP | N | C | Q S | Q S | Q S | Q S | C |
| C | C | Q | N | N | C | N | C | Q | Q | Q | Q | C |
| C | C | C | C | C | C | N | C | Q | Q | Q | Q | C |
| C | C | C | N | C | C | N | C | C | C | C | C | C |
| C | C | C | C | C | C | N | C | C | C | C | C | C |
| N | C | Q | C | N | QP | N | Q | Q | Q | Q | Q | C |
| P | P | P | P | P | P | N | P | P | P | P | P | P |
| C | Q S | Q | Q | Q | QP | N | QP | QP | QP | QP | QP | C |
| C | Q | C | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| P | QP | P | C | QP | QP | N | QP | Q | Q | Q | Q | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | N | P | P | N | P | P | P | P | P | P |
| C | P | P | C | C | C | N | C | C | C | C | C | C |
| C | Q | Q | C | Q | Q | N | Q | C | C | C | C | C |
| N | C | N | N | C | N | N | N | N | N | N | N | N |
| C S | Q S | C | C | C | P | N | C | C S | C S | C S | C S | C S |
| N | N | N | C S | N | N | N | N | N | N | N | N | N |
| C | C | Q | C | Q | Q | N | C | Q | Q | Q | Q | C |
| P | N | P | N | QP | N | N | QP | N | N | N | N | P |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| C | Q | Q | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| C | C | Q | N | Q | Q | N | C | C | C | C | C | C |
| C S | C | Q | Q | Q | Q | N | Q | C | C | C | C | C S |
| C | Q | Q | Q S | Q | QP | N | 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 | C | N | N | N | N | N |
| C | N | N | N | N | N | N | C | C | C | C | C | C |
| P | Q S | C | C | Q S | QP | N | Q | P | P | P | P | P |
| C | C | C | C | N | C | N | C | C | C | C | C | C |
| C | N | N | C | Q | N | N | C | Q | Q | Q | Q | C |
| C | QPS | C | C | C | Q | N | C | C | C | C | C | C |
| N | N | C | N | Q | N | N | Q | C | C | C | C | C |
| N | N | C | N | C | N | N | Q | C | C | C | C | C |
| N | C | C | N | C | N | N | Q | C | C | C | C | C |
| N | N | C | N | C | N | N | Q | C | C | C | C | C |
| N | C | C | N | C | N | N | Q | C | C | C | C | C |
| N | QP | C | N | Q | QP | N | C | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | C | Q S | Q | N | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | P | QP | P | N | P | QP | QP | QP | QP | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | N | Q | N | N | 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 |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| C | C | C | C | C | C | N | Q | C | C | C | C | C |
| N | Q S | N | N | N | N | N | N | N | N | N | N | N |
| P | P | C | C | C | C | N | C | P | P | P | P | P |
| C | QPS | Q | Q | QP | Q | N | P | Q | Q | Q | Q | C |
| C | C | C | N | N | C | N | C | C | C | C | C | C |
| C | Q | C | C | Q | C | N | C | Q | Q | Q | Q | C |
| C | N | N | N | N | N | N | C | N | N | N | N | C |
| C | C | Q | C | Q | Q | N | C | C | C | C | C | C |
| N | N | P | N | N | Q | N | N | Q | Q | Q | Q | C |
| C | P | P | C | QP | QP | N | C | Q | Q | Q | Q | C |
| C | N | P | N | N | Q | N | Q | C | C | C | C | C |
| N | N | P | N | N | N | N | N | N | N | N | N | N |
| C | C | C | C | Q | C | N | C | Q | Q | Q | Q | C |
| P | N | N | N | N | N | N | N | P | P | P | P | P |
| C | Q | Q | C | Q | Q | N | C | Q | Q | Q | Q | C |
| C | C | Q | C | Q | Q | N | Q | C | C | C | C | C |
| C | C | N | N | Q | Q | N | N | Q | Q | Q | Q | C |
| P | P | C | C | QP | P | N | QP | P | P | P | P | P |
| C | C | Q | N | N | N | N | N | Q | Q | Q | Q | C |
| C | C | C | N | N | C | N | C | C | C | C | C | C |
| C | C | C | N | N | C | N | C | C | C | C | C | C |
| C | C | N | C | C | C | N | N | C | C | C | C | C |
| N | C | N | C | C | C | N | N | C | C | C | C | C |
| C | C | N | C | C | C | N | N | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| C | C | Q | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| P | QP | QP | QP | QP | P | N | QP | P | P | P | P | P |
| P | QP | QP | QP | QP | P | N | QP | P | P | P | P | P |
| P | QP | QP | QP | QP | P | N | QP | P | P | P | P | P |
| C | N | Q | C | Q S | N | N | Q | Q S | Q S | Q S | Q S | C |
| N | N | Q | C | N | Q | N | Q | Q S | Q S | Q S | Q S | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | C | Q | N | N | Q | Q | Q | Q | Q | C |
| C | C | C | C | C | C | N | C | C | C | C | C | C |
| N | Q | N | N | N | N | N | N | Q | Q | Q | Q | N |
| P | Q | Q | C | Q | C | N | C | QP | QP | QP | QP | 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 |
| P | QP | P | QP | QP | P | N | QP | QP | QP | QP | QP | P |
| P | P | P | P | P | P | N | C | P | P | P | P | P |
| P | QP | C | N | QP | Q | N | N | QP | QP | QP | QP | P |
| C | N | P | N | N | C | N | C | C | C | C | C | C |
| C | P | P | N | N | P | N | C | C | C | C | C | C |
| C | N | P | N | N | N | N | N | N | N | N | N | C |
| N | N | N | N | C | N | N | N | C | C | C | C | C |
| P | QP | N | N | N | QP | N | QP | QP | QP | QP | QP | P |
| P | N | P | N | N | QP | N | P | P | P | P | P | P |
| C | N | N | C | N | N | N | N | Q | Q | Q | Q | C |
| C S | Q S | C | C | N | QP | N | C | Q S | Q S | Q S | Q S | C S |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| P | N | C | C | QP | N | N | C | C | C | C | C | P |
| P | QP | QP | N | C | P | N | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | N | P | QP | QP | N | QP | Q | Q | Q | Q | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | C | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| C | Q | Q | C | Q | Q | N | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | 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 | Q | Q | Q | Q | C |
| C | Q | Q | C | Q | Q | N | Q | P | P | P | P | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | N | C | N | C | N | C | C S | C S | C S | C S | C |
| C | Q | Q | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| C | Q | C | C | Q | Q | N | Q | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | C | C | C | N | C | C | C | C | C | C |
| C | N | C | N | N | N | N | N | Q | Q | Q | Q | C |
| C | C | Q | C | Q | Q | N | C | C | C | C | C | C |
| N | C | Q | N | Q | Q | N | N | Q | Q | Q | Q | C |
| N | C | Q | N | N | Q | N | N | Q | Q | Q | Q | C |
| C S | C | Q S | C S | N | C S | N | C | C S | C S | C S | C S | C S |
| N | N | N | N | N | N | N | N | Q | Q | Q | Q | N |
| P | P | QP | P | P | P | N | P | P | P | P | P | P |
| C | Q | C | N | C | C | N | C | C | C | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Aetna CVS/pharmacy Prescription Drug Plan (PDP) S5810-042 | Cigna Medicare Rx Plan One (PDP) S5617-217 | EnvisionRxPlus Silver (PDP) S7694-008 | Humana Walmart-Preferred Rx Plan (PDP) S5884-133 | SilverScript Basic (PDP) S5601-016 | SmartD Rx Saver (PDP) S0064-008 | United American - Select (PDP) S5755-079 | Fidelis Secure Comfort (HMO SNP) H5575-005 | Fidelis Secure Comfort Plus (HMO SNP) H5575-006 | Fidelis Secure Freedom (HMO SNP) H5575-011 | Fidelis Secure Independence (HMO SNP) H5575-007 | UnitedHealthcare Nursing Home Plan (HMO SNP) H3456-010 |
| 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 | N | N | N | N | QPS | QPS | QPS | QPS | C |
| P | Q | Q | C | Q | N | N | C | P | P | P | P | P |
| C | N | QP | C | QP | P | N | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | QPS | QPS | QPS | QPS | N |
| N | N | C | N | N | Q | N | N | Q | Q | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | C | Q | C | N | Q | Q | Q | Q | Q | C |
| C | QP | Q | C | Q | Q | N | Q | C | C | C | C | C |
| C | N | C | N | N | N | N | C | C | C | C | C | C |
| C | C | N | N | Q | N | N | N | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | C | C | C | N | Q | P | P | P | P | P |