Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Aetna Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| C | Q | Q | Q S | C | Q | Q | Q | Q | Q | Q | Q | 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 | Q | N | N | N | N | N | N | N | N | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | C | C | P | P | P | P | P | P | QP | QP | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | Q | Q | N | Q | Q | Q | Q | Q | Q | Q | Q |
| Q | Q | N | Q | Q | N | Q | Q | C | Q | Q | Q | C | C |
| Q | C | Q | C | N | N | Q | C | Q | C | Q | Q | Q | Q |
| P | P | QP | P | P | P | P | P | P | P | QP | QP | P | P |
| Q | Q | Q | Q | Q | Q | Q | C | Q | Q | Q | Q | Q | Q |
| 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 | C | C | N | Q | Q | Q | Q | N | N | Q | Q |
| Q | Q | C | Q | C | Q | Q | C | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | C | N | N | N | N | N | N | N |
| QP | N | P | N | N | N | QP | N | QP | N | QP | QP | P | P |
| Q | Q | Q S | Q S | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | N | QP | N | N | QP | QP | N | N | N | N | N | N | N |
| Q | N | Q | C | C | C | Q | N | Q | N | N | N | Q | Q |
| 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 |
| 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 | C | N | N | N | N | N | N | N | N | N | C | C |
| Aetna Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | P | P | P | P | P | P | P | P | P | P | P | P |
| N | C | N | C | C | Q | Q | C | Q | C | N | N | Q | Q |
| N | C | N | C | C | Q | Q | C | Q | C | N | N | Q | Q |
| N | QP | N | Q | N | N | P | QP | P | QP | P | P | P | P |
| N | N | Q | N | C | N | C | N | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | P | P | P | P |
| N | N | N | N | N | QP | QP | N | N | N | N | N | P | P |
| N | Q | Q | C | Q | N | Q S | Q | Q S | Q | Q | Q | Q | Q |
| N | C | Q | C | C | N | Q | C | N | C | N | N | Q | Q |
| C | C | C | C | C | C | C | C | C | C | C | C | C | C |
| Q | N | C | Q | C | Q | Q | N | Q | N | Q | Q | Q | Q |
| C | N | C | C S | C | N | C | C | N | N | N | N | 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 | C | C | C |
| N | N | N | N | N | N | Q | N | N | N | N | N | N | N |
| Q | Q | Q | C | C | N | Q | C | N | Q | N | N | Q | Q |
| P | N | P | P | P | P | P | N | P | N | P | P | P | P |
| Q | P | Q | QP | C | Q | QP | P | Q | C | QP | QP | C | C |
| C | Q | C | N | C | Q | Q | Q | Q | Q | C | C | Q | Q |
| QP | QP | C | Q | QP | QP | QP | QP | QP | QP | QP | QP | P | P |
| N | N | Q | N | N | N | N | N | N | N | N | N | N | N |
| C | C | P | C | C | C | C | C | C | C | C | C | C | C |
| N | N | N | C | C | N | N | N | N | N | N | N | N | N |
| P | C | P | C | C | C | C | C | C | C | P | P | C | C |
| Q | Q | Q | Q | C | Q | C | C | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q S | P | C | C S | N | C | C S | P | C S | P | QP | QP | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | Q | C | Q | Q | C | Q | C | Q | Q | Q | Q |
| N | N | N | N | N | QP | QP | N | N | N | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| Q | Q | C | Q | Q | Q | Q | C | C | Q | Q | Q | C | C |
| Q | C | Q | C | C | N | Q | C | Q | C | N | N | Q | Q |
| N | N | N | N | N | C | QP | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | Q | C | Q | C | Q | C | Q | Q | Q | Q S | Q S |
| C | N | C | N | C | Q | Q | C | N | N | N | N | C | C |
| Q | QP | Q | Q S | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | QP | N | P | N | N | N | N | N | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | C | C |
| QP | QP | QP | QP | QP | C S | P | QP | P | QP | QP | QP | QP | QP |
| C | N | C S | N | N | N | C | N | N | N | N | N | C | C |
| N | N | N | N | N | Q | Q | N | N | N | C | C | N | N |
| C | Q | Q | C S | C | C | C | Q | C | Q | C | C | C | C |
| N | N | C | N | C | C | C | N | C | N | N | N | C | C |
| N | N | C | N | C | C | C | N | C | N | N | N | C | C |
| N | N | C | N | C | C | C | N | C | N | N | N | C | C |
| N | N | C | N | C | C | C | N | C | N | N | N | C | C |
| N | N | C | N | C | C | C | N | C | N | N | N | C | C |
| N | N | C | N | C | C | C | N | C | N | N | N | C | C |
| N | N | Q | N | Q | N | Q | P | N | QP | QP | QP | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q S | Q | Q S | Q S | Q | QPS | C S | Q | C S | Q | Q | Q | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | QP | QP | QP | QP | QP | P | P | P | QP | QP | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | C | Q | C | Q | Q | N | Q | C | Q | Q | Q | Q |
| 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 Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| C | C | C | C | N | 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | C | P | P | C | C | P | C | P | C | QP | QP | QP | QP |
| C | C | C | C | N | N | C | C | C | C | N | N | C | C |
| Q S | N | N | N | N | N | Q | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | C | C | Q | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | Q | Q | N | N |
| P | P | QP | QP | P | N | P | P | P | P | QP | QP | P | P |
| N | N | N | P | C | N | P | N | C | N | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | Q | Q | Q | Q | C | C | C | Q | Q | C | C |
| QP | P | Q | Q | P | QP | P | P | P | P | Q | Q | QP | QP |
| QP | N | Q | C | P | QP | P | N | P | N | N | N | P | P |
| C | P | C | C | C | C | P | P | P | P | P | P | P | P |
| P | P | C | N | Q | Q | C | P | C | P | Q | Q | C | C |
| Q | Q | Q | Q S | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | C | N | C | N | C | N | C | N | N | N | C | C |
| QP | P | Q | Q | P | QP | QP | P | QP | P | Q | Q | QP | QP |
| Q | Q | N | N | N | N | Q | Q | C | Q | N | N | C | C |
| P | P | P | QP | P | QP | P | P | P | P | P | P | P | P |
| N | Q | N | C | Q | N | N | C | N | Q | N | N | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | N | N | C | N | C | C | C | C | C | C | C | C |
| C | C | N | C | N | C | C | C | N | C | C | C | N | N |
| C | C | N | C | N | C | C | C | N | C | C | C | N | N |
| C | C | N | C | N | C | C | C | N | C | C | C | N | N |
| N | QP | QP | N | N | QP | QP | QP | N | QP | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| Q | C | Q | C | N | N | Q | C | Q | C | C | C | Q | Q |
| Q | Q | C | C | Q | Q | Q | C | Q | C | C | C | Q | Q |
| C | C | C | P | C | C | C | C | C | C | C | C | C | C |
| Q | P | QP | QP | P | QP | P | P | P | C | QP | QP | P | P |
| C | P | QP | QP | P | QP | P | P | P | C | QP | QP | P | P |
| N | N | N | N | N | Q | Q S | N | Q | N | N | N | Q | Q |
| N | N | N | Q | N | N | Q | Q | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | C | C | Q | Q | Q | N | Q | C | C | C | Q | Q |
| 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 |
| Q | C | QP | C | C | Q | C | C | C | C | Q | Q | 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 | N | N | N | N |
| N | N | N | N | N | N | C | N | N | N | N | N | N | N |
| QP | P | P | QP | P | QP | QP | P | QP | P | QP | QP | P | P |
| P | P | P | P | P | P | P | P | P | P | P | P | P | P |
| Q | Q | Q S | Q | P | C | P | Q | P | Q | QP | QP | P | P |
| P | P | P | N | C | N | P | P | C | P | N | N | C | C |
| P | P | P | P | P | C | P | P | C | P | P | P | C | C |
| 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | P | N | P | N | P | N | N | N | P | P |
| N | Q | N | Q | N | N | N | Q | N | Q | N | N | N | N |
| Q | C | Q S | C | C | Q S | Q | C | Q | C | C | C | Q | Q |
| Aetna Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| N | N | N | N | N | N | C | N | C | N | N | N | N | N |
| QP | P | P | P | C | C | P | P | N | P | N | N | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | N | N | N | QP | QP | QP | QP | QP | N | N | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | Q | Q | N | Q | N | N | N | Q | Q |
| C | Q | C | Q S | C | Q | Q | Q | C | Q | Q | Q | C | C |
| Q | Q | Q | Q | Q | Q | C | C | C | Q | Q | Q | C | C |
| Q | Q | Q | Q | Q | N | Q | Q | Q | Q | Q | Q | Q | Q |
| 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 | Q | Q | P | Q | Q | Q | Q | Q | Q | Q |
| 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 | C | Q | Q | C | Q | Q | C | Q | C | C | C | Q | Q |
| C | C | C | Q | C | Q | Q | C | C | C | Q | Q | C | C |
| C | C | C | C | C | N | C | C | C | C | N | N | C | C |
| C | C | C | C | C | C | C | C | C | C | C | C | C | C |
| C | QP | Q | Q | C | Q | Q | QP | Q | QP | Q | Q | C | C |
| C | C | Q | C | C | Q | 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 | N | N | N | N | N | N | N |
| C S | C S | C S | C S | C | N | C S | C S | C S | C S | N | N | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | C | Q | C | C | C | P | C | P | C | QP | QP | P | P |
| Q | C | Q S | N | C | C | C | C | P | C | Q | Q | P | P |
| Aetna Medicare Rx Saver (PDP) S5810-062 | Blue MedicareRx Value (PDP) S6506-001 | Cigna-HealthSpring Rx Secure (PDP) S5617-138 | EnvisionRxPlus Silver (PDP) S7694-028 | Express Scripts Medicare - Value (PDP) S5660-130 | Humana Preferred Rx Plan (PDP) S5884-146 | Magellan Rx Medicare Basic (PDP) S4607-023 | SilverScript Choice (PDP) S5601-056 | Symphonix Value Rx (PDP) S0522-044 | WellCare Classic (PDP) S5967-165 | CareMore Touch (HMO SNP) H2593-003 | CareMore Touch (HMO SNP) H2593-019 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-006 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-005 |
| 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 | QPS | N | N | N | N | N | Q | Q |
| Q | C | QP | C | C | Q | C | C | C | C | Q | Q | QP | QP |
| N | P | QP | Q | C | QP | C | P | C | P | QP | QP | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | N | N | N | Q | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | Q | Q | C | Q | Q | C | Q | C | Q | Q | Q | Q |
| Q | Q | Q | Q | Q | Q | C | C | C | Q | Q | Q | Q | Q |
| QP | QP | C | QP | Q S | Q | QP | QP | C | QP | N | N | Q | Q |
| N | N | N | N | N | Q | QP | N | P | N | N | N | N | N |
| N | N | C | N | C | N | C | N | C | N | 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 |
| QP | C | P | P | C | C | P | C | P | C | QP | QP | QP | QP |