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Search 2014 Top Long-Term Care Prescription Drugs
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Below, you will find a chart of the most popular long-term care (or LTC) drugs cross-referenced to both the Medicare Part D prescription drug plans (PDPs) qualifying for the Low-Income Subsidy (LIS) $0 monthly premium and the institutional Medicare Advantage Special Needs Plans (SNPs). The coverage overview for each drug by plan is shown within the chart. Plan coverage with no usage management restrictions is shown in dark green, drugs with quantity limits restrictions in light green, step therapy and/or prior authorization restrictions in white and no plan coverage is shown in red.

You can click on the Medicare plan name to access the full plan formulary or click on the drug name to review coverage for this drug across all plans.

Below are Links to other State Summary Charts for the top LTC Drugs on LIS and SNP Medicare Plans:
AK  AL  AR  AZ  CA  CO  CT  DC  DE  FL  GA  HI  IA  ID  IL  IN  KS  KY  LA  MA  MD  ME  MI  MN  MO  MS  MT  NC  ND  NE  NH  NJ  NM  NV  NY  OH  OK  OR  PA  PR  RI  SC  SD  TN  TX  UT  VA  VT  WA  WI  WV  WY 

Long-Term Care (LTC) / LIS Plan Drug List Summary for MT

           

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)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
ABILIFY
Q Q Q C Q Q Q N Q QP
ABILIFY DISCMELT
Q Q Q C Q Q Q N Q QP
ACIPHEX
 N N N N N N N N N N
ACTONEL
 N N C N Q N N N N N
ACTOS
 N N N N N N N N N N
ACYCLOVIR
C C C C P P C N C C
ACYCLOVIR SODIUM
 P P P C C C P N P C
ADVAIR DISKUS
 N Q C Q N N Q N Q Q
ADVAIR HFA
 N Q C Q N N Q N Q Q
AGGRENOX
C Q Q C C S N C N Q C
ALBUTEROL SULFATE
 P P P P P P P N P P
ALENDRONATE SODIUM
C Q C Q Q Q Q N C Q
AMBIEN
 N N N N N N N N N N
AMBIEN CR
 N N N N N N N N N N
AMITIZA
Q Q Q C N N Q N Q C S
AMLODIPINE BESYLATE
C C Q Q Q Q Q N Q Q
APIDRA
 N N N C N N N N N N
ARANESP ALBUMIN FREE
 P P P N N N P N QP N
ARIXTRA
C N N N N N N N N N
ATACAND
 N N N N N N N N N N
ATACAND HCT
 N N N N N N N N N N
AVAPRO
 N N N N N N N N N N
AVELOX
C N Q N N N N N C N
AVELOX ABC PACK
C N Q N N N N N C N
AVELOX IV
C C C N C C N N C N
 AARP MedicareRx Saver Plus (PDP)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
AZATHIOPRINE
C P C P P P P N C P
BENICAR
C Q Q C N Q Q N Q S N
BENICAR HCT
C Q Q C N Q Q N Q S N
BETASERON
 N N N C N N P N P P
BONIVA
 N N P N N N N N N N
BROVANA
 P N N N QP QP N N N N
BYETTA
C N Q C QP Q S N N Q SC
BYSTOLIC
C N Q C S N N C N N C
CARVEDILOL
C C C C C C C N C C
CANDESARTAN CILEXETIL [ATACAND]
 N Q Q N N Q N N Q N
CEFTAZIDIME
C C C N C C C N C C
CEFTRIAXONE
C C C C C C C N C C
CELEBREX
 N N Q C N N Q N N C
CELLCEPT
 P P P P P P P N P P
CHANTIX
C Q Q QP Q Q QP N QP Q
COLCRYS
C C C C Q Q Q N Q C
COPAXONE
 P QP P C QP QP P N QP QP
COZAAR
 N N N N N N N N N N
CUBICIN
 P N P N P P P N P P
DEXTROSE
C P P C C C C N C C
DONEPEZIL HYDROCHLORIDE
C Q Q C Q Q Q N C C
ELESTAT
 N N N N N N N N N N
ELIDEL
C SQ SC C SC C P N C S P
ENABLEX
 N C N C S N N N N N N
ENOXAPARIN SODIUM INJECTION
Q C Q C Q Q C N Q Q
EPOGEN
 P N P N QP QP N N N N
 AARP MedicareRx Saver Plus (PDP)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
ESCITALOPRAM [LEXAPRO]
C Q Q C Q Q Q N Q Q
ESOMEPRAZOLE [NEXIUM]
C C C C N N C N C C
ESZOPICLONE [LUNESTA]
 N N P N N N Q N N N
EXELON
 N N N N N N N N N N
EXELON PATCH
C SC Q Q SQ Q Q N C Q
FENOFIBRIC ACID [TRILIPIX]
 N C Q N N Q C N Q N
FENTANYL PATCH
Q Q Q Q SQ Q Q N Q Q
FEXOFENADINE HCL
 N N N N N N N N N N
FLECTOR PATCH
 N N N N N N N N N N
FORTAZ
C N N N N N N N C N
FORTEO
 P Q SC P Q SQ SQP N P QP
FOSRENOL
C C C C N N C N C C
FRAGMIN
C N N C Q Q N N Q N
GEODON
C C C C C C Q N C SQ
HUMALOG
 N N C N N Q N N C Q
HUMALOG KWIKPEN INJECTION
 N N C N N C N N C Q
HUMALOG MIX 50/50
 N C C N N C N N C Q
HUMALOG MIX 75/25
 N N C N N C N N C Q
HUMALOG MIX KWIKPEN INJECTION
 N C C N N C N N N Q
IBANDRONATE SODIUM
 N N P N Q N QP N Q QP
INSPRA
 N N N N N N N N N N
INVEGA
Q Q Q C Q SQ SQ N C QP
IPRATROPIUM/ALBUTEROL
 N N N N N N N N N N
IPRATROPIUM BROMIDE
 P P P QP QP QP P N Q P
IPRATROPIUM BROMIDE NASAL
 N N N N N N N N N N
IRBESARTAN [AVAPRO]
C Q Q Q Q Q N N Q N
LANSOPRAZOLE TABLETS DR
 N N N N N N N N N N
LEUPROLIDE PREFILLED SYRINGE [LUPRON]
 N N N N N N N N N N
 AARP MedicareRx Saver Plus (PDP)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
LEVEMIR
C C C C C C C N C Q
LEXAPRO
 N N N N N N N N N N
LIDOCAINE DCL 1% VIAL
 P P C C C C P N P C
LIDODERM PATCH
Q QPSQ Q QP QP Q N Q Q
LOTEMAX
C C C N N N C N C C
LOVAZA
C C C C Q Q C N N C
LOVENOX
 N N N N N N N N N N
LUMIGAN
C C Q C Q Q C N C Q
LUNESTA
 N N P N N N Q N N N
LUPRON DEPOT
 P P P Q QP QP QP N Q N
MEGACE ES
C N C N N N Q N C N
MEGACE ORAL
 N N C N N N N N N N
MELOXICAM
C C C C Q Q C N Q C
MIACALCIN
 P N N N N N N N P P
MORPHINE
C P C N N Q P N C C
MORPHINE SULFATE
Q Q Q Q C Q Q N Q Q
MOXIFLOXACIN HCL [AVELOX]
C N Q N N N N N C N
NAMENDA
C C Q Q Q QP Q N C Q
NASONEX
C C N N Q Q Q N Q C
NEUPOGEN
 P P C Q QP QP P N P P
NEXIUM
C Q Q N N N C N Q C
NEXIUM IV
C C C N N N C N C N
NITRO-BID
C C C N N N C N C C
NOVOLOG
C C N C C C C N N Q S
NOVOLOG FLEXPEN
 N C N C C C C N N Q S
NOVOLOG MIX 70/30
C C N C C C C N N Q S
NUVIGIL
 N N QP N Q Q QP N N N
 AARP MedicareRx Saver Plus (PDP)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
OMEPRAZOLE
C Q Q C Q Q C N Q C
ONDANSETRON
 P QP QP QP QP QP P N P C
ONDANSETRON HCL
 P QP QP QP QP QP P N P P
ONDANSETRON ODT
 P QP QP QP QP QP P N P C
ONGLYZA
C N N Q Q SQ S N N Q Q
OXYCONTIN
 N N Q Q N N Q N N N
PALIPERIDONE (24 HR) ER [INVEGA]
 N N N N N N N N N N
PANTOPRAZOLE SODIUM
C Q Q C Q Q N N Q C
PATADAY
C C C C C C C N C C
PLAVIX
 N N N N N N N N N N
PRADAXA
QP Q Q C Q Q C N Q Q
PREVACID DELAYED RELEASE
 N N N N N N N N N N
PREVACID SOLUTAB
 N N N N N N N N N N
PRILOSEC
 N N N N N N N N N N
PROCRIT
 P QP P QP QP QP P N QP P
PROGRAF
 P P P P P P P N P P
PROLIA INJECTION
 P QP C C QP QP Q N QP Q S
PROMETHAZINE
C N C N P P P N C P
PROMETHAZINE HCL
C P C N P P P N C P
PROMETHAZINE VC
C N C N N N N N N C
PROTONIX
 N N N N N N N N C N
PROVIGIL
QP N N N N N N N N N
PULMICORT
 P N P N N N P N P N
PULMICORT FLEXHALER
C N N Q N N N N N Q
RANEXA
C S N C C Q SQ SQ N Q SQ
 AARP MedicareRx Saver Plus (PDP)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
RECLAST INJECTION
 P N N N N N N N C N
REGRANEX
 P QP QP P C C P N P P
REQUIP
 N N N N N N N N N N
REVATIO
 P QP N P N N N N C N
RHINOCORT AQUA
 N N N N N N N N N N
RISPERDAL CONSTA
C C C C Q Q Q N Q Q
RISPERIDONE
C Q Q C Q Q Q N C Q
ROZEREM
 N N N C N N N N N N
SANCTURA
 N N N N N N N N N N
SANCTURA XR
 N N N N N N N N N N
SIMVASTATIN
C Q Q Q Q Q Q N C Q
SKELAXIN
 N N N N N N N N N N
STALEVO
 N N N N N N N N N N
TAMIFLU
C Q Q Q Q Q C N Q Q
TAMSULOSIN HCL
C C C C Q Q Q N Q C
TAZICEF
 N N N N N N N N N N
TOBRAMYCIN-DEXAMETH OPTH
C C C C C C C N C C
TRANSDERM SCOP
C N C N N N QP N Q N
TRAVATAN Z
C C Q C Q Q C N C C
TRICOR
 N N N N N N N N N N
TRILIPIX
 N C Q N N N N N Q N
ULORIC
C S N Q SC S N N C S N C SC S
ULTRAM ER
 N N N N N N N N N N
VANCOMYCIN HCL
 P P QP C P P P N P P
VOLTAREN
C Q C N N N C N C C
 AARP MedicareRx Saver Plus (PDP)
S5921-370		Aetna CVS/pharmacy Prescription Drug Plan (PDP)
S5810-059		Cigna Medicare Rx Secure (PDP)
S5617-123		EnvisionRxPlus Silver (PDP)
S7694-025		HealthMarkets Value Rx (PDP)
S0128-026		Humana Preferred Rx Plan (PDP)
S5884-145		SilverScript Basic (PDP)
S5601-050		SmartD Rx Saver (PDP)
S0064-025		Symphonix Value Rx (PDP)
S0522-042		WellCare Classic (PDP)
S5967-162
VOLTAREN EYE DROPS
 N N N N N N N N N N
VOLTAREN-XR
 N N N N N N N N N N
VYTORIN
 N Q Q N N N N N QP Q
XARELTO
 P Q Q C Q Q C N C Q
XIFAXAN
C N QP C QP QP P N C C S
XOPENEX
 N N N N N N N N N N
XOPENEX HFA
 N N C N N N Q N Q N
ZEGERID
 N N N N N N N N N N
ZETIA
C Q Q C Q Q C N Q Q
ZIPRASIDONE HCL
Q Q Q C Q Q Q N C Q
ZOSYN
C N C N N N N N C N
ZYPREXA
 N N N N Q Q N N N N
ZYPREXA ZYDIS
 N N N N N N N N N N
ZYVOX
 P QP Q P C C C N P QP
           





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