Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | P | N | N | QP | QP | QP | QP | N | QP | QP | QP | QP | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | Q | Q | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | C | N | N | N | N | N | N | N | N | QP | QP | QP | QP | N |
| P | P | P | N | N | QP | QP | QP | QP | N | P | P | P | P | N |
| Q | C | Q | N | N | Q | Q | Q | Q | N | 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 | N | N | N |
| N | Q | Q | N | N | C | C | C | C | N | Q | Q | Q | Q | N |
| Q | C | C | N | N | C | C | C | C | N | Q | Q | Q | Q | N |
| N | N | N | N | N | C S | C S | C S | C S | N | N | N | N | N | N |
| N | N | N | N | N | P | P | P | P | N | P | P | P | P | N |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | QP | QP | N | N | QP | 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 | 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 |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | P | N | N | P | P | P | P | N | P | P | P | P | N |
| N | N | N | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | N | N | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| QP | QP | QP | N | N | P | P | P | P | N | C | C | C | C | N |
| N | N | N | N | N | 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 |
| QP | N | N | N | N | QP | QP | QP | QP | N | QP | QP | QP | QP | N |
| N | Q | Q | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | C | C | N | N | C | C | C | C | N | Q | Q | Q | Q | N |
| Q | N | N | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | C | N | N | N | C | C | C | C | N | C | C | C | C | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | N | QP | QP | QP | QP | N | Q | Q | Q | Q | N |
| P | N | N | N | N | N | N | N | N | N | P | P | P | P | N |
| Q | C | C | N | N | QP | QP | QP | QP | N | C | C | C | C | N |
| Q | Q | Q | N | N | N | N | N | N | N | QP | QP | QP | QP | N |
| QP | QP | QP | N | N | QP | QP | QP | QP | N | C | C | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | Q | Q | Q | Q | N | N | N | N | N | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | 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 | QP | QP | QP | QP | N | C S | C S | C S | C S | N |
| N | N | N | N | N | Q | Q | Q | Q | N | N | N | N | N | N |
| Q | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| QP | N | N | N | N | QP | QP | QP | QP | N | N | N | N | N | N |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| Q | C | Q | N | N | Q | Q | Q | Q | N | C | C | C | C | N |
| N | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| 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 |
| Q | Q | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | N | N | N | N | QP | QP | QP | QP | N | Q | Q | Q | Q | N |
| Q | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| Q | Q | Q | N | N | Q S | Q S | Q S | Q S | N | 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 | QP | QP | QP | QP | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q S | QP | QP | N | N | QP | QP | QP | QP | N | QP | QP | QP | QP | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| Q | N | N | N | N | C | C | C | C | N | N | N | N | N | N |
| C | Q | Q | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | QP | N | N | Q | Q | Q | Q | N | QP | QP | QP | QP | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | P | P | P | P | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | P | P | N | N | QP | QP | QP | QP | N | P | P | P | P | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | C | N | N | Q | Q | Q | Q | N | 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 | N | N | N |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| C | C | C | N | N | C | C | C | C | N | 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 | N | N | N | N |
| C | C | C | N | N | QP | QP | QP | QP | N | QP | QP | QP | QP | N |
| N | C | C | N | N | C | C | C | C | N | 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 |
| Q | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | P | N | N | QP | QP | QP | QP | N | P | P | P | 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 |
| Q | C | C | N | N | Q | Q | Q | Q | N | C | C | C | C | N |
| QP | P | P | N | N | Q | Q | Q | Q | N | QP | QP | QP | QP | N |
| QP | N | N | N | N | Q | Q | Q | Q | N | P | P | P | P | N |
| C | P | P | N | N | C | C | C | C | N | P | P | P | P | N |
| Q | P | P | N | N | N | N | N | N | N | C | C | C | C | N |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | N | N | N | N | C | C | C | C | N | C | C | C | C | N |
| QP | P | P | N | N | QP | QP | QP | QP | N | QP | QP | QP | QP | N |
| N | Q | N | N | N | N | N | N | N | N | P | P | P | P | N |
| QP | P | P | N | N | P | P | P | P | N | P | P | P | P | N |
| N | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| C | C | C | N | N | C | C | C | C | N | N | N | N | N | N |
| C | C | C | N | N | C | C | C | C | N | N | N | N | N | N |
| C | C | C | N | N | 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 |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| N | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| N | C | C | N | N | P | P | P | P | N | Q | Q | Q | Q | N |
| Q | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| QP | C | C | N | N | QP | QP | QP | QP | N | P | P | P | P | N |
| QP | C | C | N | N | QP | QP | QP | QP | N | P | P | P | P | N |
| Q | N | N | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| Q | C | C | N | N | C | C | C | C | N | Q | Q | Q | Q | N |
| N | Q | N | N | N | Q S | Q S | Q S | Q S | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | C | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | C | N | N | Q | Q | Q | Q | N | QP | 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | P | P | P | P | N |
| QP | P | P | N | N | QP | QP | QP | QP | N | P | P | P | P | N |
| P | P | P | N | N | P | P | P | P | N | P | P | P | P | N |
| Q | Q | Q | N | N | QP | QP | QP | QP | N | C | C | C | C | N |
| C | P | P | N | N | P | P | P | P | N | C | C | C | C | N |
| C | P | P | N | N | P | P | P | P | N | C | C | C | C | N |
| N | N | N | N | N | P | P | P | P | N | N | N | N | N | N |
| 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 | N | N |
| N | Q | Q | N | N | Q | Q | Q | Q | N | N | N | N | N | N |
| Q S | C | C | N | N | C S | C S | C S | C S | N | Q | Q | Q | Q | N |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | P | P | N | N | N | N | N | N | N | P | P | P | P | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | QP | QP | N | N | QP | QP | QP | QP | N | QP | QP | QP | QP | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | N | N | N | Q S | Q S | Q S | Q S | N | Q | Q | Q | Q | N |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | C | C | C | C | N |
| Q | C | Q | N | N | Q | Q | Q | Q | N | C | C | C | C | N |
| N | N | N | N | N | Q | Q | Q | Q | N | 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 | N | N | N |
| Q | Q | Q | N | N | Q | Q | Q | Q | N | 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 | P | P | P | P | N |
| Q | C | C | N | N | C | C | C | C | N | Q | Q | Q | Q | N |
| Q | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| N | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| C | C | C | N | N | C | C | C | C | N | C | C | C | C | N |
| Q | QP | QP | N | N | Q | Q | Q | Q | N | C | C | C | C | N |
| Q | C | C | N | N | C | C | C | C | N | 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 | C S | C S | N | N | C S | C S | C S | C S | N | C S | C S | C S | C S | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | N | N | QP | QP | QP | QP | N | C | C | C | C | N |
| C | C | N | N | N | Q | Q | Q | Q | N | P | P | P | P | N |
| Humana Preferred Rx Plan (PDP) S5884-105 | SilverScript Choice (PDP) S5601-022 | WellCare Classic (PDP) S4802-083 | Capela Nursing Home Plan (HMO SNP) H4627-009 | Flamenco Nursing Home Plan (HMO SNP) H4627-004 | Simply Care (HMO SNP) H5471-008 | Simply Care (HMO SNP) H5471-053 | Simply Comfort (HMO SNP) H5471-009 | Simply Comfort (HMO SNP) H5471-055 | Sonata Community Plan (HMO SNP) H4627-005 | UnitedHealthcare Assisted Living Plan (PPO SNP) H0710-012 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-004 | UnitedHealthcare Nursing Home Plan (PPO SNP) H0710-010 | Waltz Community Plan (HMO SNP) H4627-010 |
| 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 | N | N | N |
| N | N | N | N | N | QP | QP | QP | QP | N | Q | Q | Q | Q | N |
| Q | C | C | N | N | Q | Q | Q | Q | N | QP | QP | QP | QP | N |
| QP | P | P | N | N | QP | QP | QP | QP | N | P | P | P | P | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | N | 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 |
| Q | N | N | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| Q | C | Q | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | N |
| Q | QP | QP | N | N | QP | QP | QP | QP | N | Q | Q | Q | Q | N |
| Q | N | N | N | N | QP | 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 | 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 | N | N | N | N | N |