Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Cigna Secure Rx (PDP) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 | N | P | P | P | P | P | N | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | N | N | Q | Q | Q | C | Q | N | Q | Q | Q |
| Q | N | Q | N | N | Q | Q | Q | C | Q | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | Q | N | C | C | C | C | Q | N | C | C | C |
| N | N | N | N | N | N | N | N | C | 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 | C | 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 |
| P | N | N | N | N | N | N | N | N | N | N | P | P | P |
| Q | N | Q | Q | N | Q | Q | Q | Q | Q | N | Q | Q | Q |
| Q | N | Q | Q | N | Q | Q | Q | Q | Q | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | QP | N | N | QP | QP | QP | QP | N | N | 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 |
| Cigna Secure Rx (PDP) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 | N | QP | QP | QP | P | QP | N | Q | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | QP | N | N | N | N |
| N | N | N | N | N | Q | Q | Q | N | N | N | Q | Q | Q |
| C | N | C | Q | N | Q | Q | Q | C | Q | N | Q | Q | Q |
| Q | N | Q | Q | N | N | N | N | C | Q | N | Q | Q | Q |
| N | N | C | Q | N | C | C | C | C | Q | N | C | C | C |
| N | N | N | N | N | N | N | N | N | Q | N | N | N | N |
| P | N | C | C | N | C | C | C | C | C | N | C | C | C |
| C | N | C | C | N | C | C | C | C | C | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | C | Q | N | Q | Q | Q | C | Q | N | Q | Q | Q |
| N | N | N | P | N | N | N | N | N | P | N | N | N | N |
| C | N | C | Q | N | P | C | C | C | Q | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | N | P | QP | N | QP | N | N | P | 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 | C | N | N | N | N | N | C | Q S | N | N | N | N |
| C | N | P | C | N | C | C | C | C | C | N | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | N | C | C | C | C | C | N | C | C | C |
| Q | N | C | Q | N | Q | Q | Q | C | Q | 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 | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| Q | N | Q | Q | N | Q | C | C | C | Q | N | C | C | C |
| N | N | C | Q | N | N | C S | C S | C | Q | N | Q | Q | Q |
| 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 | Q | N | N | N | N | N | N | N | N |
| Q | N | C | Q | N | C | C | C | C | Q | N | Q | Q | Q |
| N | N | C | Q | N | N | N | N | C | Q | N | Q | Q | Q |
| C S | N | N | N | N | N | N | N | P | N | N | C S | C S | C S |
| C | N | N | N | N | N | N | N | C | N | N | C | C | C |
| Q | N | Q | Q | N | QP | QP | QP | QP | Q | 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 | N | N | N | N | N | N | N | N | N |
| N | N | N | QP | N | P | P | P | P | QP | N | 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 | C | N | N | N | N | N |
| N | N | N | N | N | Q | N | N | N | N | N | C | C | C |
| N | N | N | N | N | Q | N | N | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | N | N | C | C | C |
| Q | N | Q | N | N | Q | P | P | C | Q | 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 | C | C | 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 | C | C | N | N | N | N |
| C | N | C | Q | N | Q | Q | Q | C | Q | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | N | Q | C | C | C | Q | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | N | Q | Q | Q | C | Q | 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 | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| C | N | C | C | N | C | C | C | C | C | 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 | N | N |
| QP | N | P | Q | N | QP | Q | Q | C | Q | N | Q | Q | Q |
| C | N | N | C | N | C | C | C | N | C | 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 | N | N |
| N | N | Q | N | N | N | N | N | C | N | N | Q | Q | Q |
| C | N | C | Q | N | C | C | C | C | Q | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | QP | N | P | P | P | P | QP | N | 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 | N | C | Q | N | C | C | C | C | Q | N | C | C | C |
| QP | N | Q | QP | N | QP | P | P | C | QP | N | QP | QP | QP |
| QP | N | C | QP | N | N | N | N | C | QP | N | 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 | 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 S | N | N | N | N |
| N | N | N | QP | N | N | N | N | N | QP | N | C S | C S | 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 | N | N | N | N |
| N | N | C | N | N | C | C | C | C | N | N | C | C | C |
| N | N | C | C | N | C | C | C | C | C | N | N | N | N |
| N | N | C | C | N | C | C | C | C | C | N | N | N | N |
| N | N | C | C | N | C | C | C | C | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| C | N | C | Q | N | Q | Q | Q | C | Q | N | Q | Q | Q |
| N | N | C | N | N | N | N | N | C | Q | 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 | N | N | N | N | N | N | N | N | N |
| P | N | P | QP | N | P | C | C | QP | QP | N | P | P | P |
| P | N | P | QP | N | P | C | C | QP | QP | N | P | P | P |
| N | N | N | N | N | N | N | N | N | Q | N | N | N | N |
| C | N | C | Q | N | Q | Q | Q | C | Q | N | Q | Q | Q |
| N | N | N | N | N | 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 | C | Q | N | Q | C | C | C | Q | 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 | C S | Q | N | N | N | N | C | Q | N | Q S | Q S | Q S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | Q | N | Q | Q | Q | 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 | P | P | P |
| P | N | QP | N | N | P | P | P | N | N | N | P | P | P |
| P | N | P | P | N | P | P | P | P | P | N | P | P | P |
| Q | N | Q | Q | N | Q | Q | Q | C | QP | N | Q | Q | Q |
| P | N | C | C | N | P | P | P | C | C | N | C | C | C |
| N | N | N | N | N | N | N | N | C | N | N | 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 |
| N | N | N | N | N | Q | Q | Q | 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 |
| Q | N | Q | Q | N | C | C | C | C | Q | N | Q | Q | Q |
| Cigna Secure Rx (PDP) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | P | N | QP | QP | QP | P | P | N | 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 | N | N | N | N | N | C | Q | N | Q | Q | Q |
| C | N | C | Q | N | Q | Q | Q | C | Q | N | C | C | C |
| Q | N | Q | Q | N | Q | Q | Q | C | Q | 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 | N | N |
| Q | N | C | Q | N | QP | QP | QP | C | Q | N | C | C | C |
| Q | N | C | C | N | Q | Q | Q | C | C | 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 | 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 | C | C | C | N | N | N | C | C | C |
| C | N | C | C | N | C | C | C | C | C | N | C | C | C |
| N | N | C | N | N | N | N | N | C | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | N | N | N | N | N | C | Q | 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 | 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 | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-219 | Clear Spring Health Value Rx (PDP) S6946-007 | Elixir RxSecure (PDP) S7694-010 | Humana Basic Rx Plan (PDP) S5884-135 | Indy Health SaverRx (PDP) S3535-010 | SilverScript Choice (PDP) S5601-020 | WellCare Classic (PDP) S4802-082 | WellCare Medicare Rx Saver (PDP) S5810-044 | Georgia Health Advantage (HMO I-SNP) H8093-001 | Humana Together in Health (PPO I-SNP) H5216-242 | PruittHealth Premier (HMO I-SNP) H3291-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-004 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-013 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-033 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 | QP | N | P | P | P | C | QP | N | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | C | N | Q | Q | Q | Q | C | 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 | N | N | N | C | N | N | N | N | N |
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