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) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 | C | P | P | P | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | Q | N | Q | Q | Q | N | Q | Q | Q | Q | Q |
| N | Q | Q | Q | N | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | C | Q | C | C | C | C | C | C | C | C | C |
| C | N | N | N | N | N | N | 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 | Q | Q | Q | N | Q | Q | Q | N | Q | 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 |
| P | QP | N | N | N | N | N | N | PS | P | P | P | P | P |
| Q | Q | Q | Q | Q | Q | Q | Q | P | Q | Q | Q | Q | Q |
| Q | Q | Q | Q | Q | Q | Q | Q | QP | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| N | 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 | 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 | QP | QP | QP | QP | QP | QP | QP | N | Q | Q | Q | Q | Q |
| N | N | N | 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 |
| N | N | N | N | N | Q | Q | Q | N | Q | Q | Q | Q | Q |
| N | C | C | C | Q | Q | Q | Q | C | Q | Q | Q | Q | Q |
| N | Q | Q | Q | Q | N | N | C | N | Q | Q | Q | Q | Q |
| C | N | C | C | Q | 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 | C | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | C | C | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | P | N | N | N | N | N | N | N | N | N |
| C | C | C | C | Q | P | C | C | C | C | C | C | C | C |
| N | N | N | N | Q | Q | Q | Q | N | Q | Q | Q | Q | Q |
| N | QP | 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 | C | C | N | N | N | N | N | N | N | N | N | N |
| P | P | P | P | C | C | C | C | P | P | P | P | P | P |
| 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 | C |
| Q | Q | C | C | Q | Q | Q | Q | Q | Q | 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 | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| C | Q | Q | Q | Q | C | C | C | C | C | C | C | C | C |
| N | N | C | C | Q | N | C S | C S | C | Q | Q | Q | Q | Q |
| N | N | N | 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 | Q | N | N | N | N | N | N | N | N |
| Q | Q | C | C | Q | C | C | C | Q | Q | Q | Q | Q | Q |
| N | N | C | C | Q | N | N | N | N | Q | Q | Q | Q | Q |
| C S | Q S | C | N | N | N | N | N | C S | C S | C S | C S | C S | C S |
| N | Q | N | N | N | N | N | C | C | C | C | C | C | C |
| Q | Q | Q | Q | Q | QP | QP | QP | Q | Q | 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 | QP | QP | QP | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | N | N | QP | P | P | P | C | QP | QP | QP | QP | QP |
| N | N | N | N | N | N | N | N | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | C | N | N | N | N | N |
| C | Q | N | N | C | Q | Q | Q | C | C | C | C | C | C |
| C | Q | N | N | C | Q | Q | Q | C | C | C | C | C | C |
| C | C | N | N | N | N | N | N | N | C | C | C | C | C |
| C | C | N | N | N | N | N | N | N | C | C | C | C | C |
| C | C | N | N | N | N | N | N | N | C | C | C | C | C |
| C | C | N | N | N | N | N | N | N | C | C | C | C | C |
| C | C | N | N | N | N | N | N | N | C | C | C | C | C |
| C | C | N | N | N | N | N | N | N | C | C | C | C | C |
| Q | Q | Q | Q | N | P | P | P | Q | Q | 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 | N | N | N | N | N | N | N |
| N | N | C | 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 |
| C | Q | Q S | Q S | Q | Q | Q | Q | P | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | QP | 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 |
| Q | Q | Q | Q | Q | C | C | C | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | Q | C | C | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | Q | C | C | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| N | 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 |
| N | N | N | N | 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 | P | P | Q | C | C | C | P | Q | Q | Q | Q | Q |
| N | C | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | C | C | 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 | C | C | C | Q | C | C | C | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | P | QP | P | P | P | C | 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 |
| C | C | C | C | Q | C | C | C | C | C | C | C | C | C |
| QP | QP | Q | Q | QP | P | P | P | C | QP | QP | QP | QP | QP |
| P | QP | C | C | QP | N | N | N | C | 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 |
| Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | 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 | N | N | N | N | N | N | N | N | N | N |
| N | N | QP | QP | QP | N | N | N | N | C S | C S | C S | C S | C S |
| 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 |
| C | N | C | C | N | C | C | C | C | C | C | C | C | C |
| N | N | C | C | C | C | C | C | C | N | N | N | N | N |
| N | N | C | C | C | C | C | C | C | N | N | N | N | N |
| N | N | 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 |
| AARP MedicareRx Saver Plus (PDP) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| N | C | C | C | Q | C | C | C | C | Q | Q | Q | Q | Q |
| N | N | C | C | N | N | N | P | C | Q | Q | Q | Q | Q |
| Q | Q | C | C | Q | C | C | C | C | Q | 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 |
| P | P | P | P | QP | P | C | C | P | P | P | P | P | P |
| P | P | P | P | QP | P | C | C | P | P | P | P | P | P |
| Q | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| 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 |
| Q | Q | C | C | Q | C | C | C | C | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C S | N | C S | C S | C | N | N | N | C | C S | C S | C S | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | N | Q | Q | Q | 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 | N |
| N | N | N | N | N | N | N | N | N | P | P | P | P | P |
| P | N | QP | QP | N | P | P | P | N | P | P | P | P | P |
| P | P | P | P | P | P | P | P | P | P | P | P | P | P |
| Q | Q | Q | Q | Q | Q | Q | Q | P | Q | Q | Q | Q | Q |
| C | P | C | C | C | P | P | P | C | C | C | C | C | C |
| C | N | N | N | N | N | N | N | C | C | C | C | C | C |
| 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 | N | N | 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 | N | N | N | N | N | N |
| Q | N | N | N | N | Q | Q | Q | 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 | C | C | C | C | Q | Q | Q | Q | Q |
| AARP MedicareRx Saver Plus (PDP) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | P | P | C | QP | QP | QP | Q | 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 | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | N | N | N | C | C | Q | Q | Q | Q | Q |
| C | Q | C | C | Q | Q | Q | Q | P | C | C | C | C | C |
| C | Q | Q | Q | Q | Q | Q | Q | 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 |
| C | Q | C | C | Q | QP | QP | QP | C | C | C | C | C | C |
| Q | Q | C | C | C | Q | Q | Q | C | Q | 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 | N | N | N | N | N | N | N | N | N | N |
| C | Q | C | C | Q | C | C | C | C | C | C | 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 | N | C | C | N | N | N | N | Q | C | C | C | C | C |
| N | N | N | N | Q | C | C | C | Q | N | N | N | N | N |
| N | C | C | C | Q | N | N | N | Q | 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 |
| 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 | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-374 | Cigna-HealthSpring Rx Secure (PDP) S5617-148 | Clear Spring Health Value Rx (PDP) S6946-025 | EnvisionRxPlus (PDP) S7694-030 | Humana Basic Rx Plan (PDP) S5884-113 | SilverScript Choice (PDP) S5601-060 | WellCare Classic (PDP) S4802-020 | WellCare Medicare Rx Saver (PDP) S5810-064 | AgeRight Advantage Health Plan (HMO I-SNP) H1372-001 | UnitedHealthcare Assisted Living Plan (HMO I-SNP) H3113-008 | UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP) H2228-017 | UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP) H0710-037 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-016 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-036 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | 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 | C | C | QP | P | P | P | QP | P | P | P | P | P |
| 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 | N |
| N | N | N | N | 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 | C | Q | Q | Q | Q | Q |
| Q | Q | Q | Q | Q | QP | QP | QP | Q | Q | 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 | C | N | N | N | N | N |
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