Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | 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 | C | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | N | Q | Q | Q | Q | C | C |
| Q | N | Q | N | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | Q | C | C | C | C | C | C |
| 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 | Q | C | C |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| P | N | P | N | N | N | N | P | N | N |
| Q | N | Q | Q | Q | Q | Q | Q | Q | Q |
| Q | N | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | QP | 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 | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | 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 | QP | QP | QP | QP | QP | Q | P | P |
| N | 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 | Q | Q | Q | Q | N | N |
| C | N | C | Q | Q | Q | Q | Q | C | C |
| Q | N | Q | Q | N | N | N | Q | C | C |
| N | N | N | Q | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| P | N | P | C | C | C | C | C | C | C |
| C | N | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | Q | Q | Q | C | C |
| N | N | N | P | N | N | N | N | N | N |
| C | N | C | Q | P | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| QP | N | QP | QP | QP | N | N | N | 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 | C | C |
| C | N | C | C | C | C | C | P | C | C |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | C | C | C |
| Q | N | 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 |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| Q | N | Q | Q | Q | C | C | C | C | C |
| N | N | Q | Q | N | C S | C S | Q | C | C |
| N | N | N | N | N | N | N | Q | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q | N | N | N | N | N |
| Q | N | Q | Q | C | C | C | Q | C | C |
| N | N | N | Q | N | N | N | Q | C | C |
| C S | N | C S | N | N | N | N | C S | P | P |
| C | N | C | N | N | N | N | C | C | C |
| Q | N | QP | Q | QP | QP | QP | Q | 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 | QP | P | P | P | QP | P | P |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | C | C |
| N | N | N | N | Q | N | N | C | N | N |
| N | N | N | N | Q | N | N | C | N | N |
| C | N | C | N | N | N | N | C | N | N |
| C | N | C | N | N | N | N | C | N | N |
| C | N | C | N | N | N | N | C | N | N |
| C | N | C | N | N | N | N | C | N | N |
| C | N | C | N | N | N | N | C | N | N |
| C | N | C | N | N | N | N | C | N | N |
| Q | N | Q | N | Q | P | P | Q | C | C |
| 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 | C | C |
| N | N | N | N | N | N | N | N | C | C |
| C | N | Q | Q | Q | Q | Q | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | 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 |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| C | 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 | N |
| QP | N | QP | Q | QP | Q | Q | Q | C | C |
| C | N | 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 | Q | C | C |
| C | N | C | Q | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| P | N | P | 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 |
| Q | N | Q | Q | C | C | C | C | C | C |
| QP | N | QP | QP | QP | P | P | QP | C | C |
| QP | N | QP | QP | N | N | N | P | 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 | 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 | 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 |
| N | N | C | N | C | C | C | C | C | C |
| N | N | N | C | C | C | C | N | C | C |
| N | N | N | C | C | C | C | N | C | C |
| N | N | N | C | C | C | C | N | C | C |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| C | N | C | Q | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | 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 |
| P | N | P | QP | P | C | C | P | QP | QP |
| P | N | P | QP | P | C | C | P | QP | QP |
| N | N | N | N | N | N | N | N | N | N |
| C | N | Q | Q | Q | Q | Q | Q | C | C |
| N | N | N | N | QP | QP | QP | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | 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 | Q | N | N | N | Q S | C | C |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | P | N | N |
| P | N | P | N | P | P | P | P | N | N |
| P | N | P | P | P | P | P | P | P | P |
| Q | N | Q | Q | Q | Q | Q | Q | C | C |
| P | N | N | C | P | P | P | C | C | C |
| N | N | N | N | N | N | N | C | C | C |
| N | 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 | N | N | N | N |
| N | N | N | N | Q | Q | Q | N | N | N |
| N | N | N | N | Q | Q | Q | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | C | C | C | Q | C | C |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| N | N | N | N | N | N | N | N | N | N |
| P | N | P | P | QP | QP | QP | 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 | Q | C | C |
| C | N | Q | Q | Q | Q | Q | C | C | C |
| Q | N | Q | Q | 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 | N | N | N |
| Q | N | Q | Q | QP | QP | QP | C | C | C |
| Q | N | Q | C | 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 |
| P | N | P | N | C | C | C | C | N | N |
| C | N | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-118 | Clear Spring Health Value Rx (PDP) S6946-021 | Express Scripts Medicare - Value (PDP) S5660-126 | Humana Basic Rx Plan (PDP) S5884-109 | SilverScript Choice (PDP) S5601-048 | WellCare Classic (PDP) S4802-088 | WellCare Medicare Rx Saver (PDP) S5810-058 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Kansas Health Advantage (HMO I-SNP) H2392-001 | Kansas Health Advantage Plus (HMO I-SNP) H2392-002 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | 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 | QP | QP | P | P | P | P | 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 |
| Q | N | Q | C | 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 | 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 |