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Search 2019 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 MO

           

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)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
ABILIFY
Q Q Q Q C P P C
ABILIFY DISCMELT
 N N N N N N N N
ACIPHEX
 N N N N N N N N
ACTONEL
 N N N N N N N N
ACTOS
 N N N N N N N N
ACYCLOVIR
QP P P P P P P QP
ACYCLOVIR SODIUM
 N N N N N N N N
ADVAIR DISKUS
Q N Q Q Q Q Q Q
ADVAIR HFA
Q N Q Q Q Q Q Q
AGGRENOX
 N N N N N N N N
ALBUTEROL SULFATE
 P P P P P P P P
ALENDRONATE SODIUM
Q Q C C C C C Q
AMBIEN
 N N N N N N N N
AMBIEN CR
 N N N N N N N N
AMITIZA
Q N Q Q N N N Q
AMLODIPINE BESYLATE
C C C C C C C C
APIDRA
 N N N N N N N N
ARANESP ALBUMIN FREE
 N N N N PS PS PS P
ARIPIPRAZOLE [Abilify]
Q Q Q Q P P P Q
ARIPIPRAZOLE ODT [Abilify Discmelt]
Q Q Q Q QP QP QP Q
ARIXTRA
 N N N N N N N N
ARMODAFINIL [NUVIGIL]
QP N QP QP QP QP QP N
ASPIRIN-DIPYRIDAM [Aggrenox]
 N N N N N N N N
ATACAND
 N N N N N N N N
ATACAND HCT
 N N N N N N N N
AVAPRO
 N N N N N N N N
AVELOX
 N N N N N N N N
AVELOX ABC PACK
 N N N N N N N N
AVELOX IV
 N N N N N N N N
 Aetna Medicare Rx Saver (PDP)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
AZATHIOPRINE
 N N N N N N N N
AZATHIOPRINE SODIUM
 P P P P P P P P
BENICAR
 N N N N N N N N
BENICAR HCT
 N N N N N N N N
BETASERON
QP QP QP QP N N N C
Bimatoprost [Lumigan]
 N N N N Q Q Q N
BONIVA
 N N N N N N N N
BROVANA
 N P N N N PS P N
BYETTA
Q N Q Q N N C Q
BYSTOLIC
Q Q Q Q C C C Q
CANDESARTAN CILEXETIL [ATACAND]
Q Q N N N N N Q
CARBIDOPA-LEVODOPA-ENTACAPONE [STALEVO]
 N C C C C C C C
CARVEDILOL
C C C C C C C C
CEFTAZIDIME
C C C C C C C C
CEFTRIAXONE
C C C C C C C C
CELEBREX
 N N N N N N N N
CELECOXIB [Celebrex]
Q Q Q Q Q Q Q Q
CELLCEPT
 N P N N N N N N
CHANTIX
 P Q P C C C C C
COLCRYS
Q Q Q Q N N N Q
COPAXONE
 N QP QP N N N N N
COZAAR
 N N N N N N N N
CUBICIN
 N N N N N N N N
DAPTOMYCIN [Cubicin]
C C C C C C C C
DARIFENACIN [Enablex]
 N N N N N N C N
DEXTROSE
C C C C C C C P
DICLOFENAC EPOLAMINE [Flector]
 N N N N N N QP QP
DICLOFENAC SOD ER [Voltaren-XR]
C C C C C C C C
DONEPEZIL HYDROCHLORIDE
Q Q Q Q Q SQ SQ SQ
ELESTAT
 N N N N N N N N
ELIDEL
 N C N N C C C C S
ENABLEX
 N N N N N N N N
ENOXAPARIN SODIUM INJECTION
C Q C C Q Q Q Q
EPOGEN
 N QP N N P P P N
 Aetna Medicare Rx Saver (PDP)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
ESCITALOPRAM [LEXAPRO]
Q Q C C C C C C
ESOMEPRAZOLE [NEXIUM]
 N Q Q C C C C Q
ESZOPICLONE [LUNESTA]
 N N N N Q Q Q N
EXELON
 N N N N N N N N
EXELON PATCH
 N N Q N N N N N
Ezetimibe [Zetia]
C Q C C Q Q Q Q
Ezetimibe-Simvastatin [Vytorin]
 N N N N N N Q Q
FENOFIBRIC ACID [TRILIPIX]
C N N N C C C C
FENTANYL PATCH
QP Q QP QP Q Q Q Q
FEXOFENADINE HCL
 N N N N N N N N
FLECTOR PATCH
 N N N N N N QP QP
FORTAZ
 N N N N N N N N
FORTEO
 P QP P P C C C QP
FOSRENOL
 N N N N C C C N
FRAGMIN
 N N N N C C C N
GEODON
Q C Q Q C C C C
GLATIRAMER [Copaxone]
Q C Q Q C C C C
HUMALOG
 N N N N N N N C
Humalog PEN
 N N N N N N N C
HUMALOG KWIKPEN INJECTION
 N N N N N N N C
HUMALOG MIX 50/50
 N N N N N N N C
HUMALOG MIX 75/25
 N N N N N N N C
HUMALOG MIX KWIKPEN INJECTION
 N N N N N N N C
IBANDRONATE SODIUM
 N N P P Q Q Q Q
INSPRA
 N N N N N N N N
INVEGA
Q Q Q Q C P P C
IPRATROPIUM/ALBUTEROL
 N N N N N N N N
IPRATROPIUM BROMIDE
QP QP P P P P P P
IPRATROPIUM BROMIDE NASAL
 N N N N N N N N
IRBESARTAN [AVAPRO]
Q Q C C C C C Q
LANSOPRAZOLE [Prevacid]
 N N Q C C C C Q
LANTHANUM CARBONATE CHEW [Fosrenol]
 N N Q C C C C Q
LEUPROLIDE PREFILLED SYRINGE [LUPRON]
 N N N N N N N N
 Aetna Medicare Rx Saver (PDP)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
LEVEMIR
C C C C C C C C
LEXAPRO
 N N N N N N N N
LIDOCAINE DCL 1% VIAL
 N N N N N N N N
LIDODERM PATCH
 N N N N N N N N
LINEZOLID [Zyvox]
QP Q C C P P P Q
LOTEMAX
C C C C C C C C
LOTEPREDNOL ETABONATE [LOTEMAX]
 N N C C C C C C
LOVAZA
 N N N N N N N N
LOVENOX
 N N N N N N N N
LUMIGAN
C Q C C Q Q Q C
LUNESTA
 N N N N N N N N
LUPRON DEPOT
 P QP P P C C C P
MEGACE ES
 N N N N N N N N
MEGACE ORAL
 N N N N N N N N
MELOXICAM
C Q C C C C C C
Memantine HCl [Namenda]
QP QP P P C C C QP
Memantine HCl [Namenda Titration]
QP QP N N C C C P
MIACALCIN
 N N N N N N N N
MORPHINE
 N N N N N N N N
MORPHINE SULFATE
QP Q Q Q Q Q Q Q
MOXIFLOXACIN HCL [AVELOX]
 N N N N C C C C
NAMENDA
 N N N N N N C N
NASONEX
 N N N N N N N N
NEUPOGEN
 P QP P P N N N C S
NEXIUM
 N N N N C C C Q
NEXIUM IV
 N N N N N N N N
NITRO-BID
C N C C C C C C
NOVOLOG
C C C C C C C N
NOVOLOG FLEXPEN
C C C C C C C N
NOVOLOG MIX 70/30
C C C C C C C N
NUVIGIL
 N N N N N N N N
 Aetna Medicare Rx Saver (PDP)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
OLMESARTAN MEDOXOMIL [Benicar]
 N Q C C C C C Q
OMEGA-3 ETHYL ESTERS [Lovaza]
Q N N N C C C Q
OMEPRAZOLE [Prilosec]
Q Q C C C C C Q
OMEPRAZOLE-BICARBONATE [Zegerid]
 N N N N N N N N
ONDANSETRON
QP QP P C P P P P
ONDANSETRON HCL
 P QP P C P P P P
ONDANSETRON ODT
 P QP P C P P P P
ONGLYZA
 N Q N N N N N Q
Oseltamivir Phosphate [Tamiflu]
C Q Q Q Q Q Q Q
OXYCONTIN
 N N QP N N N N N
PALIPERIDONE (24 HR) ER [INVEGA]
 N N N N N N N N
PANTOPRAZOLE SODIUM
Q Q C C C C C Q
PATADAY
 N N N N N N N N
PIMECROLIMUS [Elidel]
 N C N N C C C C S
PLAVIX
 N N N N N N N N
PRADAXA
C Q C C C C C Q
PREVACID DELAYED RELEASE
 N N N N N N N N
PREVACID SOLUTAB
 N N N N N N N N
PRILOSEC
 N N N N N N N P
PROCRIT
 P QP P P P P P P
PROGRAF
 P P P P P P P P
PROLIA INJECTION
Q Q Q Q P P P Q
PROMETHAZINE
 P C P P C C C C
PROMETHAZINE HCL
 P N N N C C C C
PROMETHAZINE VC
 N N N N C C C N
PROTONIX
 N N N N N N N N
PROVIGIL
 N N N N N N N N
PULMICORT
 N N N N N N N N
PULMICORT FLEXHALER
Q N Q Q N N N N
RANEXA
C Q S N N C C C Q
RANOLAZINE [Ranexa]
C Q SC C C C C Q
 Aetna Medicare Rx Saver (PDP)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
RECLAST INJECTION
 N N N N N N N N
REGRANEX
QP C P P Q Q Q P
REQUIP
 N N N N N N N N
REVATIO
 N QP N N N N N N
RHINOCORT AQUA
 N N N N N N N N
RISEDRONATE SODIUM [ACTONEL]
Q N N N C C C Q
RISPERDAL CONSTA
Q Q Q Q C P P C
RISPERIDONE
Q Q Q Q C C C C
ROZEREM
 N N N N QP QP QP Q
SANCTURA
 N N N N N N N N
SANCTURA XR
 N N N N N N N N
SCOPOLAMINE TD [Transderm Scop]
QP Q QP QP C C C C
SIMVASTATIN
Q Q Q Q C C C Q
SKELAXIN
 N N N N N N N N
STALEVO
 N N N N N N C P
TAMIFLU
 N N N N N N N N
TAMSULOSIN HCL
Q Q C C C C C C
TAZICEF
C N C C C C C C
TOBRAMYCIN-DEXAMETH OPTH
C C C C C C C C
TRANSDERM SCOP
QP N QP QP N N N C
TRAVATAN Z
C Q C C Q Q Q C
TRICOR
 N N N N N N N N
TRILIPIX
 N N N N N N N N
ULORIC
C S N C SC SC SC SC SC S
ULTRAM ER
 N N N N N N N N
VANCOMYCIN HCL
Q Q C C Q Q Q C
VOLTAREN
 N N C N N N N N
 Aetna Medicare Rx Saver (PDP)
S5810-052		Humana Preferred Rx Plan (PDP)
S5884-140		SilverScript Choice (PDP)
S5601-036		WellCare Classic (PDP)
S4802-072		Missouri Medicare Select (HMO SNP)
H4490-001		NHC Advantage (HMO SNP)
H4172-001		NHC Advantage Gold (HMO SNP)
H4172-002		UnitedHealthcare Nursing Home Plan (PPO SNP)
H0710-016
VOLTAREN EYE DROPS
 N N N N N N N N
VOLTAREN-XR
 N N N N N N N N
VYTORIN
 N N N N N N N N
XARELTO
 N N N N N N N N
XIFAXAN
 P QP P P QP QP QP P
XOPENEX
 N N N N N N N N
XOPENEX HFA
 N N Q N N N Q S N
ZEGERID
 N N N N N N N N
ZETIA
 N N N N N N N N
ZIPRASIDONE HCL
Q Q Q Q C C C Q
ZOLPIDEM TARTRATE [Ambien, Edluar, Zolpimist]
QP Q QP QP Q Q Q Q
ZOLPIDEM TARTRATE ER [Ambien, Edluar, Zolpimist]
 N N N N N N N N
ZOSYN
 N N N N C C C N
ZYPREXA
 N N N N N N N N
ZYPREXA ZYDIS
 N N N N N N N N
ZYVOX
 N N N N N N N N
           





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