Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| C | Q | C | Q | 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 | 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 | QP | QP | QP | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | Q | Q | Q | Q | Q | Q | Q | C | C |
| N | Q | Q | N | Q | Q | Q | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | P | P | P | P | P | QP | QP | QP | P | P | P |
| Q | Q | Q | Q | C | C | C | Q | Q | Q | 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 | Q | Q | N | Q | Q | Q | Q | Q | Q | Q | C | 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 |
| P | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C S | C S |
| Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q S | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | QP | N | QP | QP | QP | N | N | N | 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 | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| 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 |
| N | N | N | 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 | QP | QP | P | P | 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 | P | N | N | N | N | N | N | N | P | P |
| N | Q | N | N | Q | Q | Q | Q | Q | Q | N | P | P |
| N | Q | C | Q | Q | Q | Q | C | C | C | C | C | C |
| N | Q | Q | Q | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | N | N | 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 | 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 | N | N | N | N | N |
| N | Q | C | Q | Q | Q | Q | P | P | P | Q | C S | C S |
| N | N | N | P | N | N | N | N | N | N | N | P | P |
| C | P | C | Q | P | P | C | QP | QP | QP | Q | C S | C S |
| N | Q | N | Q | Q | Q | Q | N | N | N | N | Q | Q |
| N | N | QP | QP | N | QP | N | QP | QP | QP | QP | 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 |
| C | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | C | N | N | N | N | Q | Q | Q | N | N | N |
| P | C | C | C | C | C | C | C | C | C | P | C | C |
| N | N | N | N | N | N | N | N | N | N | P | N | N |
| C | C | C | C | C | C | C | C | C | C | C | C | C |
| Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C S | N | N | C | N | N | N | QP | QP | QP | N | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | Q | Q | C | C | C | Q | Q | Q | C | C | C |
| N | N | N | QP | N | N | N | N | N | N | QP | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| C | Q | Q | Q | C | C | C | Q | Q | Q | C | C | C |
| N | N | C | Q | Q | Q | C | Q | Q | Q | N | C S | C S |
| 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 | N | N | N | N | Q | N | N | N | N | N | N | N |
| Q | C | C | Q | C | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | N | N | N | N | N | N | N | N | N | Q | Q |
| Q | QP | Q | Q | QP | QP | QP | QP | QP | QP | 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 | N | N | N | N | N | N | N |
| N | P | N | QP | P | P | P | QP | QP | QP | QP | 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 |
| C | Q | Q S | C | Q | Q | Q | Q | Q | Q | Q | C | C |
| C | Q | Q S | C | Q | Q | Q | Q | Q | Q | Q | C | C |
| C | N | N | N | N | N | N | C | C | C | N | C | C |
| C | N | N | N | N | N | N | C | C | C | N | C | C |
| C | N | N | N | N | N | N | C | C | C | N | C | C |
| C | N | N | N | N | N | N | C | C | C | N | C | C |
| C | N | N | N | N | N | N | C | C | C | N | C | C |
| C | N | N | N | N | N | N | C | C | C | N | C | C |
| Q | N | Q | N | P | P | P | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q S | Q | Q | Q | Q | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | QP | QP | P | P | P | QP | QP | QP | QP | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | Q | C | C | C | C | C | C | C | C | C |
| N | N | N | N | Q | Q | C | Q | Q | Q | N | C | C |
| N | N | N | N | Q | Q | C | Q | Q | Q | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| 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 |
| Q | QP | P | Q | C | C | C | QP | QP | QP | C | C | C |
| N | C | C | C | C | C | C | N | N | N | C | N | N |
| N | N | C | N | C | C | C | 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 | C | C | Q | C | C | C | C | C | C | Q | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | QP | QP | P | P | P | QP | QP | QP | C | 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 |
| C | C | C | Q | C | C | C | C | C | C | C | C | C |
| QP | QP | Q | QP | P | P | P | QP | QP | QP | Q | C | C |
| P | QP | C | QP | N | N | 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 | N | N |
| Q | QP | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | C |
| C | N | N | N | N | N | N | N | N | N | 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 | P | QP | QP | P | P | P | P | P | 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 |
| C | C | C | N | C | C | C | C | C | C | C | C | C |
| N | C | C | C | C | C | C | N | N | N | Q | N | N |
| N | C | C | C | C | C | C | N | N | N | Q | N | N |
| N | C | C | C | C | C | C | N | N | N | Q | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| N | N | C | Q | C | C | C | C | C | C | C | C | C |
| N | Q | C | N | N | N | N | C | C | C | Q | C | C |
| Q | Q | C | Q | C | C | C | Q | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | QP | P | P | C | N | N | N | N | P | P |
| P | P | P | QP | P | P | C | QP | QP | QP | P | P | P |
| P | P | P | QP | P | P | C | QP | QP | QP | P | P | P |
| Q | N | N | Q | N | N | N | N | N | N | N | C | C |
| Q | C | Q | Q | Q | Q | Q | C | C | C | Q | C | C |
| N | N | N | N | N | QP | N | N | N | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | C | Q | C | C | C | Q | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C S | N | C S | C | N | N | N | QP | QP | QP | C | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | N | Q | C | C | C | Q | Q | Q | Q S | 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 |
| P | P | QP | QP | P | P | P | P | P | P | QP | P | P |
| P | P | P | P | P | P | P | P | P | P | P | P | P |
| Q | Q | Q | Q | Q | Q | Q | QP | QP | QP | Q | P | P |
| C | P | C | C | P | P | P | P | P | P | P | P | P |
| C | P | N | N | N | N | N | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | 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 | N | N | N | N | N | N | N | N | P | P |
| Q | Q | N | N | Q | Q | Q | N | N | N | N | N | N |
| Q | C | Q | Q S | N | N | N | C | C | C | N | N | N |
| Q | C | Q | Q S | C | C | C | C | C | C | C | P | P |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | C | P | P | P | N | N | N | N | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 | Q | Q | N | N | N | N | N | N | N | N | C S | C S |
| C | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C | C |
| C | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | Q | Q | Q | 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 |
| C | QP | C | Q | QP | QP | QP | Q | Q | Q | QP | C | C |
| Q | Q | C | Q | Q | Q | Q | C | C | C | 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 | N | N | N | N | N | N | N | N |
| C | Q | C | Q | C | C | C | C | C | C | C | C | C |
| C | C | N | N | C | C | C | C | C | C | C | C | C |
| C | C | C | C | C | C | C | C | C | C | C | C | C |
| C | QP | C | N | QP | QP | QP | N | N | N | QP | N | N |
| N | C | C | Q | C | C | C | C | C | C | 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 |
| C S | C S | N | N | C S | C S | C S | N | N | N | Q | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | C | Q | C | C | C | QP | QP | QP | P | C | C |
| N | N | N | N | N | C | N | N | N | N | C | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-376 | Aetna Medicare Rx Saver (PDP) S5810-066 | EnvisionRxPlus (PDP) S7694-032 | Humana Preferred Rx Plan (PDP) S5884-114 | Journey Rx Standard (PDP) S6986-006 | SilverScript Choice (PDP) S5601-064 | WellCare Classic (PDP) S4802-094 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-005 | Anthem Care On Site (HMO SNP) H0544-050 | Brand New Day Select Care Plan (HMO SNP) H0838-041 | SCAN Healthy at Home (HMO SNP) H9104-006 | SCAN Healthy at Home (HMO SNP) H9104-006 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | C | QP | P | P | P | QP | QP | QP | QP | P | P |
| N | N | N | N | N | N | N | N | N | N | N | P | P |
| 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | C | C |
| Q | QP | Q | Q | QP | QP | QP | N | N | N | QP | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | C | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |