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) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| Q | C | Q | P | C |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| QP | P | P | P | QP |
| N | N | N | N | N |
| Q | Q | Q | Q | Q |
| Q | Q | Q | Q | Q |
| N | N | N | N | N |
| P | P | P | P | P |
| Q | Q | C | C | Q |
| N | N | N | N | N |
| N | N | N | N | N |
| Q | Q | Q | N | Q |
| C | C | C | C | C |
| N | N | N | N | N |
| N | N | N | PS | P |
| Q | Q | Q | P | Q |
| Q | Q | Q | QP | Q |
| 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 |
| 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) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| N | N | N | N | N |
| P | P | P | P | P |
| N | N | N | N | N |
| N | N | N | N | N |
| QP | QP | QP | N | C |
| N | N | N | Q | N |
| N | N | N | N | N |
| N | N | N | PS | N |
| Q | N | Q | N | Q |
| Q | C | Q | C | Q |
| Q | Q | N | N | Q |
| N | C | C | C | C |
| C | C | C | C | C |
| C | C | C | C | C |
| C | C | C | C | C |
| N | N | N | N | N |
| Q | C | Q | Q | Q |
| N | N | N | N | N |
| P | C | P | C | C |
| Q | N | Q | N | Q |
| N | QP | QP | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| C | C | C | C | C |
| N | C | N | N | N |
| C | C | C | C | P |
| N | N | N | N | QP |
| C | C | C | C | C |
| Q | Q | Q | Q S | Q |
| N | N | N | N | N |
| N | N | N | C | C S |
| N | N | N | N | N |
| C | Q | C | Q | Q |
| N | N | N | P | N |
| Aetna Medicare Rx Saver (PDP) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| Q | Q | C | C | C |
| N | C | Q | C | Q |
| N | N | N | Q | N |
| N | N | N | N | N |
| N | N | Q | N | N |
| C | C | C | Q | Q |
| N | N | N | N | Q |
| C | N | N | C | C |
| QP | Q | QP | Q | Q |
| N | N | N | N | N |
| N | N | N | N | QP |
| N | N | N | N | N |
| P | N | P | C | QP |
| N | N | N | C | N |
| N | N | N | C | N |
| Q | Q S | Q | C | C |
| Q | Q S | Q | C | C |
| N | N | N | N | C |
| N | N | N | N | C |
| N | N | N | N | C |
| N | N | N | N | C |
| N | N | N | N | C |
| N | N | N | N | C |
| N | Q | P | Q | Q |
| N | N | N | N | N |
| Q | Q S | Q | P | C |
| N | N | N | N | N |
| QP | QP | P | P | P |
| N | N | N | N | N |
| Q | Q | C | C | Q |
| N | N | Q | C | Q |
| N | N | Q | C | Q |
| N | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| C | C | C | C | C |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| QP | P | C | P | Q |
| C | C | C | C | C |
| N | C | C | C | C |
| N | N | N | N | N |
| N | N | N | N | N |
| C | C | C | Q | C |
| N | N | N | N | N |
| P | QP | P | C | P |
| N | N | N | N | N |
| N | N | N | N | N |
| C | C | C | C | C |
| QP | Q | P | C | QP |
| QP | C | N | C | P |
| N | N | N | N | N |
| N | N | N | N | N |
| QP | Q | Q | Q | Q |
| N | N | N | C | C |
| N | N | N | N | N |
| N | N | N | N | N |
| P | QP | P | N | C S |
| N | N | N | C | Q |
| N | N | N | N | N |
| C | C | C | C | C |
| C | C | C | C | N |
| C | C | C | C | N |
| C | C | C | C | N |
| N | N | N | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| N | C | C | C | Q |
| Q | C | N | C | Q |
| Q | C | C | C | Q |
| N | N | N | N | N |
| QP | P | P | P | P |
| P | P | P | P | P |
| P | P | P | P | P |
| N | N | N | N | Q |
| C | Q | Q | Q | Q |
| N | N | QP | N | N |
| N | N | N | N | N |
| Q | C | C | C | Q |
| N | N | N | N | N |
| N | C S | N | C | C S |
| N | N | N | N | N |
| C | N | C | C | Q |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | P |
| P | QP | P | P | P |
| P | P | P | P | P |
| Q | Q | Q | P | Q |
| P | C | P | C | C |
| P | N | N | C | C |
| N | N | N | C | N |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| Q | N | Q | N | N |
| C | Q | N | C | Q |
| C | Q | C | C | Q |
| Aetna Medicare Rx Saver (PDP) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| N | N | N | N | N |
| QP | P | P | Q | P |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| Q | Q | N | C | Q |
| Q | C | Q | P | C |
| Q | Q | Q | C | C |
| N | N | N | QP | Q |
| N | N | N | N | N |
| N | N | N | N | N |
| QP | C | QP | C | C |
| Q | C | Q | C | Q |
| N | N | N | N | N |
| N | N | N | N | P |
| N | N | N | N | N |
| Q | C | C | C | C |
| C | N | C | C | C |
| C | C | C | C | C |
| QP | C | QP | N | C |
| C | C | C | Q | C |
| N | N | N | N | N |
| N | N | N | N | N |
| C S | N | C S | C S | C S |
| N | N | N | N | N |
| Q | C | C | Q | C |
| N | N | C | N | N |
| Aetna Medicare Rx Saver (PDP) S5810-043 | EnvisionRxPlus (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | PruittHealth Premier (HMO SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (HMO-POS SNP) H5322-001 |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| P | C | P | QP | P |
| N | N | N | N | N |
| N | N | Q | N | N |
| N | N | N | N | N |
| N | N | N | N | N |
| Q | Q | Q | C | Q |
| QP | Q | QP | Q | Q |
| 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 |