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) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| C S | Q | Q | Q | Q S | Q S | Q S | Q S | Q S | Q S | C |
| C S | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | N | Q S | Q S | N | N | N | N | N | N | N |
| N | Q | Q | Q | Q S | Q S | Q S | Q S | Q S | Q S | C |
| C | Q S | Q S | Q S | Q | Q | Q | Q | Q | Q | C |
| C | P | P | P | C | C | C | C | C | C | C |
| P | C | C | C | C | C | C | C | C | C | P |
| N | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | C | C S | C S | Q | Q | Q | Q | Q | Q | C |
| P | P | P | P | P | P | P | P | P | P | P |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| N | N | Q | Q | N | N | N | N | N | N | N |
| N | N | Q | Q | N | N | N | N | N | N | N |
| C | C | C | C | Q S | Q S | Q S | Q S | Q S | Q S | C |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| C | N | C | C | C | C | C | C | C | C | C |
| P | N | QP | QP | QPS | QPS | QPS | QPS | QPS | QPS | P |
| C | N | Q | Q | N | N | N | N | N | N | C |
| N | N | Q | Q | N | N | N | N | N | N | N |
| N | N | Q | Q | N | N | N | N | N | N | N |
| N | N | QP | QP | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | C | C | C | C |
| C | N | C | C | N | N | N | N | N | N | C |
| C | C | C | C | C | C | C | C | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| C | P | P | P | C | C | C | C | C | C | C |
| C | N | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | N | Q | Q | Q S | Q S | Q S | Q S | Q S | Q S | C |
| N | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| N | N | QP | QP | N | N | N | N | N | N | P |
| P | QP | QP | QP | P | P | P | P | P | P | P |
| C | Q S | Q S | Q S | Q | Q | Q | Q | Q | Q | C |
| C | N | 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 | C | C | C | C | C | C | C | C | C | C |
| N | N | Q | Q | Q S | Q S | Q S | Q S | Q S | Q S | C |
| P | P | P | P | P | P | P | P | P | P | P |
| C | Q | Q | Q | QP | QP | QP | QP | QP | QP | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| N | N | Q | Q | N | N | N | N | N | N | N |
| P | P | P | P | C | C | C | C | C | C | P |
| C | C | C | C | C | C | C | C | C | C | C |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| N | C | C | C | C S | C S | C S | C S | C S | C S | N |
| C S | C | C | C | Q | Q | Q | Q | Q | Q | C S |
| N | N | Q | Q | Q | Q | Q | Q | Q | Q | N |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| P | QP | QP | QP | N | N | N | N | N | N | P |
| AARP MedicareRx Saver Plus (PDP) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | QP | QP | C | C | C | C | C | C | C |
| C S | Q | Q | Q | Q | Q | Q | Q | Q | Q | C S |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | C | C | C | C | C | C | N |
| C | N | C | C | N | N | N | N | N | N | C |
| P | Q S | Q S | Q S | QP | QP | QP | QP | QP | QP | P |
| C | N | C S | C S | C | C | C | C | C | C | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | C | QP | QP | Q | Q | Q | Q | Q | Q | C |
| N | Q | Q | Q | C | C | C | C | C | C | C |
| N | C | C | C | C | C | C | C | C | C | C |
| N | C | C | C | C | C | C | C | C | C | C |
| N | C | C | C | C | C | C | C | C | C | C |
| N | C | C | C | C | C | C | C | C | C | C |
| N | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | N | P | P | N | N | N | N | N | N | N |
| C | Q S | Q S | Q S | Q S | Q S | Q S | Q S | Q S | Q S | C |
| N | N | N | N | N | N | N | N | N | N | N |
| P | QP | QP | QP | P | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | Q | 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 | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| C | C | C | C | C | C | C | C | C | C | C |
| N | N | QP | QP | N | N | N | N | N | N | N |
| P | C | C | C | C | C | C | C | C | C | P |
| C | QP | QP | QP | C | C | C | C | C | C | C |
| C | N | C | C | C | C | C | C | C | C | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | N | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | P | P | P | P | P | P | C |
| N | N | P | P | Q S | Q S | Q S | Q S | Q S | Q S | C |
| C | QP | QP | QP | P | P | P | P | P | P | C |
| C | N | P | P | N | N | N | N | N | N | C |
| N | N | P | P | N | N | N | N | N | N | N |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| P | N | QP | QP | N | N | N | N | N | N | P |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| P | QP | QP | QP | P | P | P | P | P | P | P |
| C | N | Q | Q | Q | Q | Q | Q | Q | Q | 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 | 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 | C |
| N | N | QP | QP | QP | QP | QP | QP | QP | QP | N |
| AARP MedicareRx Saver Plus (PDP) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| C | Q S | Q S | Q S | Q | Q | Q | Q | Q | Q | C |
| N | N | QP | QP | Q | Q | Q | Q | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| C | C | C | C | C | C | C | C | C | C | C |
| N | N | QP | QP | N | N | N | N | N | N | N |
| P | Q | Q | Q | C | C | C | C | C | C | P |
| N | N | QP | QP | N | N | N | N | N | N | N |
| N | N | Q | Q | N | N | N | N | N | N | N |
| N | N | QP | QP | N | N | N | N | N | N | N |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| P | P | P | P | N | N | N | N | N | N | P |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| C | N | P | P | P | P | P | P | P | P | C |
| C | N | P | P | P | P | P | P | P | P | C |
| C | N | P | P | P | P | P | P | P | P | C |
| N | C | Q | Q | N | N | N | N | N | N | C |
| P | N | QP | QP | N | N | N | N | N | N | P |
| P | N | P | P | N | N | N | N | N | N | P |
| C | N | Q | Q | C | C | C | C | C | C | C |
| C S | N | Q S | Q S | QP | QP | QP | QP | QP | QP | C S |
| AARP MedicareRx Saver Plus (PDP) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| P | QP | QP | QP | P | P | P | P | P | P | P |
| P | C | C | C | QP | QP | QP | QP | QP | QP | P |
| N | N | QP | QP | N | N | N | N | N | N | N |
| P | QP | QP | QP | QP | QP | QP | QP | QP | QP | P |
| N | N | Q S | Q S | C S | C S | C S | C S | C S | C S | N |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| N | N | Q S | Q S | Q S | Q S | Q S | Q S | Q S | Q S | C |
| N | N | P | P | N | N | N | N | N | N | N |
| N | N | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | P | P | P | P | P | P | C |
| N | N | QP | QP | N | N | N | N | N | N | N |
| C | N | C | C | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | C | C | C | C | C | C | C | C |
| C | N | QP | QP | C | C | C | C | C | C | C |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| N | Q | Q | Q | N | N | N | N | N | N | C |
| N | N | Q | Q | C S | C S | C S | C S | C S | C S | C |
| C S | N | Q S | Q S | P | P | P | P | P | P | C S |
| N | N | Q S | Q S | N | N | N | N | N | N | N |
| P | P | P | P | P | P | P | P | P | P | P |
| C | C | C | C | C | C | C | C | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-356 | Humana Walmart-Preferred Rx Plan (PDP) S5884-105 | Humana Gold Plus SNP-I H1036-185 (HMO SNP) H1036-185 | Humana Gold Plus SNP-I H1036-187 (HMO SNP) H1036-187 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-010 | Simply Care (HMO SNP) H5471-017 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-011 | Simply Comfort (HMO SNP) H5471-018 | UnitedHealthcare Nursing Home Plan (PPO SNP) H5417-001 |
| N | N | P | P | N | N | N | N | N | N | N |
| N | N | P | P | N | N | N | N | N | N | N |
| N | N | Q | Q | QPS | QPS | QPS | QPS | QPS | QPS | C |
| P | Q | Q | Q | QP | QP | QP | QP | QP | QP | P |
| C | QP | QP | QP | Q | Q | Q | Q | Q | Q | C |
| N | N | P | P | N | N | N | N | N | N | N |
| N | N | Q S | Q S | C | C | C | C | C | C | N |
| N | N | QP | QP | N | N | N | N | N | N | N |
| C | Q | Q | Q | C | C | C | C | C | C | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | C |
| C | N | C | C | N | N | N | N | N | N | C |
| C | Q | QP | QP | N | N | N | N | N | N | C |
| N | N | QP | QP | N | N | N | N | N | N | N |
| P | C | C | C | QP | QP | QP | QP | QP | QP | P |