Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Cigna Secure Rx (PDP) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| 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 | N | N | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | N | Q | Q | C | C | N | N | C | Q |
| Q | N | Q | N | Q | Q | C | C | N | N | C | Q |
| N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | Q | C | C | C | C | N | N | C | C |
| N | N | N | N | N | N | C | C | 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 | C | 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 |
| P | N | P | N | N | N | N | N | N | N | N | P |
| Q | N | Q | Q | Q | Q | Q | Q | N | N | Q | Q |
| Q | N | Q | Q | Q | Q | Q | Q | N | N | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | QP | QP | QP | QP | N | N | 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 |
| Cigna Secure Rx (PDP) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| 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 | P | P | N | N | P | Q |
| N | N | N | N | N | N | C | C | 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 | Q | N | N | N | N | N | Q |
| C | N | C | Q | Q | Q | C | C | N | N | C | Q |
| Q | N | Q | Q | N | N | C | C | N | N | C | Q |
| N | N | N | Q | C | C | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | C | C | C | C | C | N | N | C | C |
| C | N | C | C | C | C | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | Q | C | C | N | N | C | Q |
| N | N | N | P | N | N | N | N | N | N | N | N |
| C | N | C | Q | P | C | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| QP | N | QP | QP | QP | N | P | P | 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 | C | C | N | N | C | N |
| C | N | C | C | C | C | C | C | N | N | C | P |
| N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | C | N | N | C | C |
| Q | N | Q | Q | Q | Q | C | C | N | N | 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 | N | N | N | N | N | N | N | N |
| 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) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| Q | N | Q | Q | Q | C | C | C | N | N | C | C |
| N | N | Q | Q | N | C S | C | C | N | N | C | Q |
| 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 | Q | N | N | N | N | N | N | N |
| Q | N | Q | Q | C | C | C | C | N | N | C | Q |
| N | N | N | Q | N | N | C | C | N | N | C | Q |
| C S | N | C S | N | N | N | P | P | N | N | P | C S |
| C | N | C | N | N | N | C | C | N | N | C | C |
| Q | N | QP | Q | QP | QP | QP | QP | N | N | QP | 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 | QP | P | P | P | P | N | N | P | QP |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | C | C | N | N | C | N |
| N | N | N | N | Q | N | N | N | N | N | N | C |
| N | N | N | N | Q | N | N | N | N | N | N | C |
| C | N | C | N | N | N | N | N | N | N | N | C |
| C | N | C | N | N | N | N | N | N | N | N | C |
| C | N | C | N | N | N | N | N | N | N | N | C |
| C | N | C | N | N | N | N | N | N | N | N | C |
| C | N | C | N | N | N | N | N | N | N | N | C |
| C | N | C | N | N | N | N | N | N | N | N | C |
| Q | N | Q | N | Q | P | C | C | N | N | C | Q |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | C | C | N | N | C | N |
| N | N | N | N | N | N | C | C | N | N | C | N |
| N | N | N | N | N | N | C | C | N | N | C | N |
| C | N | Q | Q | Q | Q | C | C | N | N | C S | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | C | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | Q | C | C | N | N | 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 | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| C | N | N | C | C | C | C | C | 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 | N | N |
| QP | N | QP | Q | QP | Q | C | C | N | N | C | Q |
| C | N | C | C | C | C | 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 | C | C | N | N | C | Q |
| C | N | C | Q | C | C | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | QP | P | P | P | P | 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 |
| Q | N | Q | Q | C | C | C | C | N | N | C | C |
| QP | N | QP | QP | QP | P | C | C | N | N | C | QP |
| QP | N | QP | QP | N | N | C | C | N | N | C | 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 | C | C | 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 | QP | N | N | N | N | 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 |
| N | N | C | N | C | C | C | C | N | N | C | C |
| N | N | N | C | C | C | C | C | N | N | C | N |
| N | N | N | C | C | C | C | C | N | N | C | N |
| N | N | N | C | C | C | C | C | N | N | C | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| C | N | C | Q | Q | Q | C | C | N | N | C | Q |
| N | N | N | N | N | N | C | C | N | N | 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 | N | N | N | N | N | N | N | N |
| P | N | P | QP | P | C | QP | QP | N | N | QP | P |
| P | N | P | QP | P | C | QP | QP | N | N | QP | P |
| N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | Q | Q | Q | Q | C | C | N | N | C | Q |
| N | N | N | N | QP | QP | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | C | C | C | N | N | 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 | Q | N | N | C | C | N | N | C | Q S |
| 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 | N | N | N | N | N | N | 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 | P | N | P | P | N | N | N | N | N | P |
| P | N | P | P | P | P | P | P | N | N | P | P |
| Q | N | Q | Q | Q | Q | C | C | N | N | C | Q |
| P | N | N | C | P | P | C | C | N | N | C | C |
| N | N | N | N | N | N | C | C | N | N | C | C |
| N | N | N | N | N | N | C | C | 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 | Q | Q | N | N | 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 | N | N | N |
| Q | N | Q | Q | C | C | C | C | N | N | C | Q |
| Cigna Secure Rx (PDP) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | P | QP | QP | P | P | 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 | N | N | N | N | C | C | N | N | C | Q |
| C | N | Q | Q | Q | Q | C | C | N | N | C S | C |
| Q | N | Q | Q | Q | Q | C | C | 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 | N | N |
| Q | N | Q | Q | QP | QP | C | C | N | N | C | C |
| Q | N | Q | C | Q | Q | C | C | N | N | 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 | 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 | N | N | N | N | N | C |
| C | N | C | C | C | C | C | C | N | N | C | C |
| N | N | N | N | N | N | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | N | N | N | C | C | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | C | N | N | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-088 | Clear Spring Health Value Rx (PDP) S6946-015 | Express Scripts Medicare - Value (PDP) S5660-120 | Humana Basic Rx Plan (PDP) S5884-140 | SilverScript Choice (PDP) S5601-036 | WellCare Classic (PDP) S4802-072 | American Health Advantage of Missouri (HMO I-SNP) H4490-001 | American Health Advantage Plus of Missouri (HMO I-SNP) H4490-002 | NHC Advantage (HMO I-SNP) H4172-001 | NHC Advantage Gold (HMO I-SNP) H4172-002 | Provider Partners Missouri Advantage Plan (HMO I-SNP) H9191-001 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-016 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| 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 | C | C | N | N | C | 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 |
| Q | N | Q | C | Q | Q | Q | Q | N | 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 | N | N | N | N | C | C | 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 |