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) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| C | QP | C | Q | Q | C | Q | 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 |
| P | QP | P | P | P | P | P | QP |
| N | N | N | N | N | N | N | N |
| Q | Q | Q | N | Q | N | Q | Q |
| Q | Q | Q | N | Q | N | Q | Q |
| N | Q S | N | N | C | N | N | QP |
| P | QP | P | P | P | P | P | P |
| Q | Q | Q | Q | C | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| Q | Q | C | N | Q | N | Q | Q |
| Q | Q | C | Q | C | C | C | Q |
| N | N | N | N | N | N | N | N |
| QP | QP | N | N | N | P | N | P |
| Q | Q S | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| QP | QP | N | QP | QP | N | 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 | C | N | N | N | C | N | C |
| Aetna Medicare Rx Saver (PDP) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| N | N | N | N | N | N | N | N |
| P | P | P | P | P | P | P | P |
| N | Q S | N | N | N | N | N | Q |
| N | Q S | N | N | N | N | N | Q |
| N | QP | N | QP | QP | N | QP | C |
| N | Q | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | N | N | QP | N | N | N | QP |
| Q | Q | Q | N | Q | Q | Q | Q |
| Q | Q | C | N | C | N | C | Q |
| Q | Q | C | Q | N | N | N | Q |
| C | C | C | N | 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 | C |
| N | N | N | N | N | N | N | N |
| Q | Q | C | N | Q | N | Q | Q |
| P | P | P | P | N | P | N | P |
| Q | Q | C | Q | C | C | C | C |
| N | N | C | Q | Q | N | Q | QP |
| QP | QP | QP | QP | QP | C | QP | C |
| N | N | N | N | N | N | N | N |
| C | P | C | C | C | C | C | C |
| C | P | C | C | C | C | C | C |
| N | Q | N | N | N | N | N | N |
| C | P | C | C | C | C | C | C |
| Q | Q | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| Q S | Q | N | C | N | C S | N | C S |
| N | Q S | N | N | N | N | N | N |
| C | Q | C | Q | C | Q | C | Q |
| N | N | N | QP | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| Q | Q | Q | Q | C | C | Q | C |
| N | Q | C | N | C | N | C | Q |
| N | N | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | N | N | Q | Q | N | N | N |
| Q | Q | N | N | C | Q | C | Q |
| N | Q | C | N | N | N | N | Q |
| C | Q | C | Q | N | N | N | C |
| Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | QP |
| N | N | N | N | N | N | N | N |
| QP | QP | QP | Q S | QP | N | QP | QP |
| C | N | N | N | N | N | N | C |
| N | N | N | Q | N | N | N | N |
| C | Q | C | C | Q | C | Q | C |
| N | C | C | N | N | C | N | C |
| N | C | C | N | N | C | N | C |
| N | C | C | N | N | C | N | C |
| N | C | C | N | N | C | N | C |
| N | C | C | N | N | C | N | C |
| N | C | C | N | N | C | N | C |
| Q | Q | Q | N | N | Q | QP | QP |
| N | N | N | N | N | N | N | N |
| C | Q | C | Q | Q | P | Q | P |
| N | N | N | N | N | N | N | N |
| QP | QP | QP | QP | P | P | P | P |
| N | N | N | N | N | N | N | N |
| Q | Q | C | Q | C | Q | C | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| C | C | N | C | 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 |
| QP | Q | C | C | C | QP | C | QP |
| C | C | N | N | C | N | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | Q S | C | Q | C | N | C | C |
| N | N | N | N | N | N | N | N |
| P | QP | P | N | P | P | P | P |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C | Q | Q | Q | C | C | C | C |
| QP | QP | P | QP | P | QP | P | QP |
| QP | QP | P | QP | N | N | N | P |
| C | C | C | C | P | P | P | P |
| P | Q | Q | Q | P | C | P | C |
| Q | Q | Q | Q | Q | Q | Q | Q |
| N | Q | C | N | N | C | N | C |
| QP | QP | P | QP | P | QP | P | QP |
| Q | N | N | N | Q | N | N | P |
| P | QP | P | QP | P | N | P | P |
| N | N | Q | N | C | N | C | Q |
| N | N | N | N | N | N | N | N |
| N | N | C | N | C | C | C | C |
| C | N | N | C | C | N | C | N |
| C | N | N | C | C | N | C | N |
| C | N | N | C | C | N | C | N |
| N | QP | N | N | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| N | Q | C | N | C | N | C | Q |
| Q | Q | N | N | C | N | C | Q |
| Q | Q | Q | Q | C | Q | C | Q |
| C | C | C | C | C | C | C | C |
| QP | QP | P | QP | C | P | C | P |
| P | QP | P | QP | C | P | C | P |
| N | N | N | Q | N | Q | N | Q |
| Q | Q | C | Q | C | Q | C | Q |
| N | N | N | N | Q | N | N | N |
| N | N | N | N | N | N | N | N |
| Q | Q | Q | Q | C | Q | C | Q |
| C | Q | C | C | C | N | C | C |
| N | N | N | N | N | N | N | N |
| Q | Q | C | Q | C | QP | C | QP |
| 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 | QP | P | N | P | P |
| P | P | P | P | P | P | P | P |
| Q | Q S | P | Q | Q | C | Q | C |
| P | P | P | C | P | C | P | C |
| P | P | P | C | P | C | P | C |
| 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 | N | N | N | N | N | N |
| N | N | N | N | Q | Q | Q | N |
| Q | Q | C | Q S | C | Q | C | Q |
| Aetna Medicare Rx Saver (PDP) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| N | N | N | N | N | N | N | N |
| QP | QP | C | C | P | P | P | P |
| N | N | N | N | N | N | N | N |
| N | N | N | QP | QP | N | QP | QP |
| N | N | N | N | N | N | N | N |
| Q | N | Q | Q | N | N | N | Q |
| C | Q | C | Q | Q | C | Q | C |
| Q | Q | Q | Q | C | C | Q | C |
| Q | Q | Q | N | N | N | N | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | P |
| Q | Q | C | Q | C | Q | C | Q |
| C | Q | C | Q | C | C | C | C |
| C | C | N | N | C | C | C | C |
| C | C | C | C | C | C | C | C |
| C | Q | C | Q | QP | C | QP | C |
| C | Q | C | Q | C | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| C S | Q S | C | N | C S | C S | C S | C S |
| N | N | N | N | N | N | N | N |
| Q | Q | C | C | C | C | C | C |
| Q | Q | C | C | C | N | N | P |
| Aetna Medicare Rx Saver (PDP) S5810-046 | Cigna-HealthSpring Rx Secure (PDP) S5617-220 | Express Scripts Medicare - Value (PDP) S5660-114 | Humana Preferred Rx Plan (PDP) S5884-106 | SilverScript Choice (PDP) S5601-024 | Symphonix Value Rx (PDP) S0522-016 | WellCare Classic (PDP) S4802-071 | UnitedHealthcare Nursing Home Plan (HMO SNP) H5008-001 |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | Q | N | N | N | N | N | Q |
| Q | Q | C | Q | C | QP | C | QP |
| N | QP | Q | QP | P | P | P | P |
| N | N | N | N | N | N | N | N |
| N | N | N | N | Q | N | N | N |
| N | N | N | N | N | N | N | N |
| Q | Q | C | Q | N | Q | N | Q |
| Q | Q | Q | Q | C | Q | Q | Q |
| QP | QP | Q S | Q | QP | Q | QP | Q |
| N | N | N | Q | N | 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 | N |
| N | N | N | C | N | N | N | N |