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) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| Q | C | Q | Q | QP | Q | Q | Q |
| Q | C | Q | Q | QP | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N |
| C | C | P | C | C | C | C | C |
| P | C | C | P | C | P | P | P |
| N | Q | N | Q | Q | Q | Q | Q |
| N | Q | N | Q | Q | C | C | C |
| C | C | N | C | C | C | C | C |
| P | P | P | P | P | P | P | P |
| C | Q | Q | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| Q | C | N | Q | C S | Q | Q | Q |
| C | Q | Q | Q | Q | C | C | C |
| N | C | N | N | N | C | C | C |
| P | N | N | P | N | P | P | P |
| C | N | N | N | N | 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 | N | N | N | N | C | C | C |
| C | N | N | N | N | C | C | C |
| C | N | C | N | N | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| C | P | P | P | P | C | C | C |
| C | C | Q | Q | N | C | C | C |
| C | C | Q | Q | N | C | C | C |
| N | C | N | P | P | P | P | P |
| N | N | N | N | N | P | P | P |
| P | N | QP | N | N | P | P | P |
| C | C | Q S | N | C | C | C | C |
| C | C S | N | C | C | C | C | C |
| C | C | C | C | C | C | C | C |
| N | N | Q | N | N | N | N | N |
| C | N | C | C | C | C | C | C |
| C | C | C | C | C | C | C | C |
| N | C | N | Q | C | C | C | C |
| P | P | P | P | P | P | P | P |
| C | QP | Q | QP | Q | C | C | C |
| C | C | Q | Q | C | C | C | C |
| P | C | QP | P | QP | P | P | 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 | C | C | C | C |
| N | N | N | N | N | N | N | N |
| C S | C S | C | P | P | C S | C S | C S |
| N | C S | N | N | N | N | N | N |
| Q | C | Q | C | Q | Q | Q | Q |
| P | N | QP | N | N | P | P | P |
| AARP MedicareRx Saver Plus (PDP) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| C | C | Q | Q | Q | C | C | C |
| C | C | N | C | C | C | C | C |
| N | N | N | Q | N | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| C S | Q S | Q | Q | Q | C S | C S | C S |
| N | N | Q | C | N | C | C | C |
| Q | Q S | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | N | N | N | N | C | C | C |
| P | P | Q S | QP | QP | P | P | P |
| C | C | N | C | C | C | C | C |
| C | C | Q | N | N | C | C | C |
| C | C | C | Q | Q | C | C | C |
| N | N | Q | N | Q | C | C | C |
| N | N | C | N | Q | C | C | C |
| N | N | C | N | Q | C | C | C |
| N | N | C | N | Q | C | C | C |
| N | N | C | N | Q | C | C | C |
| N | N | N | QP | QP | P | P | P |
| N | N | N | N | N | N | N | N |
| Q | C | Q S | Q | QP | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| P | QP | QP | P | P | P | P | P |
| N | N | N | N | N | N | N | N |
| C | Q | Q | N | N | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| C | C | C | C | Q | C | C | C |
| N | N | N | N | N | N | N | N |
| P | C | C | P | C | P | P | P |
| Q | Q | QP | Q | Q | Q | Q | Q |
| C | N | N | C | C | C | C | C |
| C | C | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N |
| C | C | Q | C | Q | C | C | C |
| N | N | N | Q | N | Q | Q | Q |
| P | Q | QP | QP | N | P | P | P |
| C | N | N | Q | N | P | P | P |
| N | N | N | N | N | N | N | N |
| C | C | Q | C | C | C | C | C |
| P | N | N | N | P | P | P | P |
| C | N | Q | P | C | C | C | C |
| Q | Q | Q | Q | Q | Q | Q | Q |
| C | N | N | N | N | C | C | C |
| C | Q | QP | Q | Q | C | C | C |
| C | N | Q | Q | C | C | C | C |
| P | Q | QP | P | P | P | P | P |
| C | N | N | C | C | C | C | C |
| C | N | N | C | N | C | C | C |
| C | N | N | C | C | C | C | C |
| C | C | C | C | Q S | C | C | C |
| N | C | C | C | Q S | C | C | C |
| C | C | C | C | Q S | C | C | C |
| N | N | Q | QP | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| C | C | Q | C | C | C | C | C |
| P | QP | QP | P | C | P | P | P |
| P | QP | QP | P | P | P | P | P |
| P | QP | QP | P | C | P | P | P |
| C | Q | Q S | N | Q | C | C | C |
| N | Q | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | C | Q | N | C | C | C | C |
| C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N |
| QP | C | Q | C | Q | QP | QP | QP |
| 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 | P | P | P | P | P |
| P | P | P | P | P | P | P | P |
| P | C | QP | Q | Q S | P | P | P |
| C | N | P | P | P | P | P | P |
| C | N | P | P | P | P | P | P |
| C | N | N | N | C | N | N | N |
| N | N | N | N | N | N | N | N |
| QP | N | N | N | N | QP | QP | QP |
| P | N | N | P | N | P | P | P |
| C | Q | N | N | Q | C | C | C |
| C S | C | Q S | Q | Q | C S | C S | C S |
| AARP MedicareRx Saver Plus (PDP) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| P | N | N | N | N | P | P | P |
| P | P | C | P | P | P | P | P |
| N | N | N | N | N | N | N | N |
| P | P | N | N | N | P | P | P |
| N | N | N | N | N | N | N | N |
| C | C | Q | Q | Q | C | C | C |
| C | C | Q | Q | Q | C | C | C |
| N | C | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | Q | Q | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | Q | Q | C | Q | C | C | C |
| C | C | Q | Q | C | C | C | C |
| N | N | N | N | N | N | N | N |
| C | C | C | C | C | C | C | C |
| C | N | N | QP | N | C | C | C |
| C | C | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C S | C S | N | C S | C S | C S | C S | C S |
| N | N | N | N | N | N | N | N |
| P | C | P | P | P | P | P | P |
| C | N | N | C | C | C | C | C |
| AARP MedicareRx Saver Plus (PDP) S5921-372 | EnvisionRxPlus Silver (PDP) S7694-027 | Humana Preferred Rx Plan (PDP) S5884-111 | SilverScript Basic (PDP) S5601-054 | WellCare Classic (PDP) S5967-164 | Erickson Advantage Guardian (HMO-POS SNP) H5322-019 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-002 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0620-002 |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | N | N | N | Q | C | C | C |
| P | C | Q | C | Q | P | P | P |
| C | C | QP | P | C S | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | C | Q | C | Q | C | C | C |
| Q | C | Q | Q | Q | Q | Q | Q |
| C | N | N | N | N | C | C | C |
| N | N | Q | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| P | P | C | C | QP | P | P | P |