Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | 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 | P | P | P | P | N | N | N | P |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | Q | N | N | N | Q |
| Q | N | Q | Q | Q | Q | N | N | N | Q |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | Q | N | N | N | C |
| 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 | 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 |
| P | N | N | N | N | N | N | N | N | P |
| Q | N | Q | Q | Q | Q | N | N | N | Q |
| Q | N | Q | Q | Q | Q | N | N | N | Q |
| N | N | N | N | N | N | N | N | N | N |
| N | N | QP | QP | QP | 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | 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 | N | P | QP | QP | QP | 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 | QP | N | N | N | N |
| N | N | N | Q | Q | N | N | N | N | Q |
| C | N | C | Q | Q | Q | N | N | N | Q |
| Q | N | Q | N | N | Q | N | N | N | Q |
| N | N | C | C | C | Q | N | N | N | C |
| N | N | N | N | N | Q | N | N | N | N |
| P | N | C | C | C | C | N | N | N | C |
| C | N | C | C | C | C | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | C | Q | Q | Q | N | N | N | Q |
| N | N | N | N | N | P | N | N | N | N |
| C | N | C | P | C | Q | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| QP | N | P | 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 | C | N | N | Q S | N | N | N | N |
| C | N | P | C | C | C | N | N | N | P |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | N | N | N | C |
| Q | N | C | Q | Q | Q | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| Q | N | Q | Q | C | Q | N | N | N | C |
| N | N | C | N | C S | Q | N | N | N | Q |
| N | N | N | N | N | N | N | N | N | Q |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | Q | N | N | N | N | N | N |
| Q | N | C | C | C | Q | N | N | N | Q |
| N | N | C | N | N | Q | N | N | N | Q |
| C S | N | N | N | N | N | N | N | N | C S |
| C | N | N | N | N | N | N | N | N | C |
| Q | N | Q | QP | QP | Q | 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 | P | P | QP | 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 | N | N | N | N | N | C |
| N | N | N | Q | N | N | N | N | N | C |
| C | N | N | N | N | N | N | N | N | C |
| C | N | N | N | N | N | N | N | N | C |
| C | N | N | N | N | N | N | N | N | C |
| C | N | N | N | N | N | N | N | N | C |
| C | N | N | N | N | N | N | N | N | C |
| C | N | N | N | N | N | N | N | N | C |
| Q | N | Q | Q | P | Q | N | N | N | Q |
| 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 | C | N | N | N | N |
| N | N | N | N | N | C | N | N | N | N |
| C | N | C | Q | Q | Q | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | C | Q | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | Q | 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 |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| C | N | C | 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 | N |
| QP | N | P | QP | Q | Q | N | N | N | Q |
| C | N | 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 | N |
| N | N | Q | N | N | N | N | N | N | Q |
| C | N | C | C | C | Q | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| P | N | P | P | P | 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 |
| Q | N | C | C | C | Q | N | N | N | C |
| QP | N | Q | QP | P | QP | N | N | N | QP |
| QP | N | C | N | N | 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 | Q S | N | N | N | N |
| N | N | N | N | N | QP | N | N | N | C S |
| 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 | N | N | N | C |
| N | N | C | C | C | C | N | N | N | N |
| N | N | C | C | C | C | N | N | N | N |
| N | N | C | C | C | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| C | N | C | Q | Q | Q | N | N | N | Q |
| N | N | C | N | N | Q | 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 |
| P | N | P | P | C | QP | N | N | N | P |
| P | N | P | P | C | QP | N | N | N | P |
| N | N | N | N | N | Q | N | N | N | N |
| C | N | C | Q | Q | Q | N | N | N | Q |
| N | N | N | QP | QP | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | C | Q | C | Q | 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 | C S | N | N | Q | N | N | N | Q S |
| N | N | N | N | N | N | N | N | N | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | P |
| P | N | QP | P | P | N | N | N | N | P |
| P | N | P | P | P | P | N | N | N | P |
| Q | N | Q | Q | Q | QP | N | N | N | Q |
| P | N | C | P | P | C | N | N | N | C |
| 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 | 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 | Q | Q | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | C | C | Q | N | N | N | Q |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N | N |
| P | N | P | QP | QP | P | 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 | Q | N | N | Q | N | N | N | Q |
| C | N | C | Q | Q | Q | N | N | N | C |
| Q | N | Q | Q | Q | Q | 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 |
| Q | N | C | QP | QP | Q | N | N | N | C |
| Q | N | C | Q | Q | C | 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 | N | N |
| P | N | N | C | C | N | N | N | N | C |
| C | N | C | C | C | C | N | N | N | C |
| N | N | C | N | N | N | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | N | N | Q | 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 |
| C | N | C | C | C | C | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-218 | Clear Spring Health Value Rx (PDP) S6946-006 | Elixir RxSecure (PDP) S7694-009 | SilverScript Choice (PDP) S5601-018 | WellCare Medicare Rx Saver (PDP) S5810-043 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | PruittHealth Premier (HMO I-SNP) H6345-002 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | 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 | N | C | P | P | 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 |
| Q | N | Q | Q | Q | C | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |