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) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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 | P | C | P | P | P | P | P | N | N | N | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | Q | Q | N | Q | Q | Q | Q | N | N | N | N | Q | Q | Q |
| N | Q | N | Q | Q | N | Q | Q | Q | Q | Q | N | N | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | N | C | C | Q | C | C | C | C | C | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | C | C | 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 | N | N | N | Q | C | 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 |
| P | P | N | N | N | N | N | N | N | P | PS | N | N | N | P | P | P |
| Q | Q | N | Q | Q | Q | Q | Q | Q | Q | C | N | N | N | Q | Q | Q |
| Q | Q | N | Q | Q | Q | Q | Q | Q | Q | Q | N | N | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | N | N | QP | QP | N | QP | QP | QP | QP | QP | 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 | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | 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 | QP | QP | Q | N | N | N | N | Q | Q | Q |
| 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 | N | N | N | N |
| N | N | N | N | N | N | Q | Q | Q | Q | N | N | N | N | Q | Q | Q |
| N | C | N | C | C | Q | Q | Q | Q | Q | C | N | N | N | Q | Q | Q |
| N | Q | N | Q | Q | Q | N | N | N | Q | C | N | N | N | Q | Q | Q |
| C | N | N | C | C | Q | C | C | C | C | C | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | P | N | C | C | C | C | C | C | C | C | N | N | N | C | C | C |
| C | C | N | C | C | C | C | C | C | C | C | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | C | C | Q | Q | Q | Q | Q | Q | N | N | N | Q | Q | Q |
| N | N | N | N | N | P | N | N | N | N | N | N | N | N | N | N | N |
| C | C | N | C | C | Q | P | C | C | C | C | N | N | N | C | C | C |
| 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | 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 |
| P | C | N | P | P | C | C | C | C | P | P | N | N | N | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | N | C | C | C | C | C | C | C | C | N | N | N | C | C | C |
| Q | Q | N | C | C | Q | Q | Q | Q | Q | Q | 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 | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
| C | Q | N | Q | Q | Q | Q | C | C | C | C | N | N | N | C | C | C |
| N | N | N | C | C | Q | N | C S | C S | Q | C | N | N | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | Q | Q | 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 | Q | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | C | C | Q | C | C | C | Q | Q | N | N | N | Q | Q | Q |
| N | N | N | C | C | Q | N | N | N | Q | N | N | N | N | Q | Q | Q |
| C S | C S | N | N | N | N | N | N | N | C S | C S | N | N | N | C S | C S | C S |
| N | C | N | N | N | N | N | N | N | C | C | N | N | N | C | C | C |
| Q | Q | N | Q | Q | Q | QP | QP | QP | Q | Q | 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 | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | QP | P | P | P | QP | C | N | N | N | QP | QP | QP |
| 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 | C | N | N | N | N | N | N |
| C | N | N | N | N | N | Q | N | N | C | N | N | N | N | C | C | C |
| C | N | N | N | N | N | Q | N | N | C | N | N | N | N | C | C | C |
| C | C | N | N | N | N | N | N | N | C | N | N | N | N | C | C | C |
| C | C | N | N | N | N | N | N | N | C | N | N | N | N | C | C | C |
| C | C | N | N | N | N | N | N | N | C | N | N | N | N | C | C | C |
| C | C | N | N | N | N | N | N | N | C | N | N | N | N | C | C | C |
| C | C | N | N | N | N | N | N | N | C | N | N | N | N | C | C | C |
| C | C | N | N | N | N | N | N | N | C | N | N | N | N | C | C | C |
| Q | Q | N | Q | Q | N | Q | P | P | Q | Q | 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 | C | 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 | C | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | N | C | Q S | Q | Q | Q | Q | C | P | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | N | Q | Q | Q | Q | C | C | C | C | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | Q | Q | Q | Q | Q | Q | Q | C | 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 | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
| N | C | N | C | C | C | C | C | C | C | C | 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 | N | N | N | N | N | N | N | N | N | N | N |
| Q | QP | N | P | P | Q | QP | Q | Q | Q | P | N | N | N | Q | Q | Q |
| N | C | N | N | C | C | C | C | C | C | C | 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 | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | Q | Q | N | N | N | N | Q | N | N | N | N | Q | Q | Q |
| N | C | N | C | C | Q | C | C | C | C | Q | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | N | P | P | QP | P | P | P | P | C | N | N | 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 |
| C | Q | N | C | C | Q | C | C | C | C | C | N | N | N | C | C | C |
| QP | QP | N | Q | Q | QP | QP | P | P | QP | C | N | N | N | QP | QP | QP |
| P | QP | N | C | C | QP | N | N | N | P | C | N | N | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | 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 | C S | C S | C S |
| 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 |
| C | N | N | C | C | N | C | C | C | C | C | N | N | N | C | C | C |
| N | N | N | C | C | C | C | C | C | N | C | N | N | N | N | N | N |
| N | N | N | C | C | C | C | C | C | N | C | N | N | N | N | N | N |
| N | N | N | C | C | C | C | C | C | 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 |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
| N | C | N | C | C | Q | Q | Q | Q | Q | C | N | N | N | Q | Q | Q |
| N | N | N | C | C | N | N | N | N | Q | C | 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 | N | N | N | N | N | N | N | N | N | N |
| P | P | N | P | P | QP | P | C | C | P | P | N | N | N | P | P | P |
| P | P | N | P | P | QP | P | C | C | P | P | N | N | N | P | P | P |
| Q | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | C | N | C | C | Q | Q | Q | Q | Q | Q | N | N | N | Q | Q | Q |
| N | 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 | N | N | N | N | N |
| Q | Q | N | C | C | Q | Q | C | C | Q | C | 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 |
| Q S | N | N | C S | C S | Q | N | N | N | Q S | C | N | N | 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 | N | N | N | Q | Q | Q | Q | 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 | P | N | N | N | N | P | P | P |
| P | P | N | QP | QP | N | P | P | P | P | N | N | N | N | P | P | P |
| P | P | N | P | P | P | P | P | P | P | P | N | N | N | P | P | P |
| Q | Q | N | Q | Q | Q | Q | Q | Q | Q | P | N | N | N | Q | Q | Q |
| C | P | N | C | C | C | P | P | P | C | C | N | N | N | C | C | C |
| C | N | N | N | N | N | N | N | N | C | C | N | N | N | C | C | C |
| 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 | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | N | N | N | N | Q | Q | Q | N | N | N | N | N | N | N | N |
| Q | 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 |
| Q | Q | N | Q | Q | Q | C | C | C | Q | C | N | N | N | Q | Q | Q |
| AARP MedicareRx Saver Plus (PDP) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | N | P | P | P | QP | QP | QP | P | Q | N | N | 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 | Q | Q | N | N | N | N | Q | C | N | N | N | Q | Q | Q |
| C | C | N | C | C | Q | Q | Q | Q | C | P | N | N | N | C | C | C |
| C | Q | N | Q | Q | Q | Q | Q | Q | C | C | N | N | N | C | C | C |
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| C | Q | N | C | C | Q | QP | QP | QP | C | C | N | N | N | C | C | C |
| Q | Q | N | C | C | C | Q | Q | Q | Q | C | N | N | N | Q | Q | Q |
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| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | P | N | N | N | N | C | C | C | C | C | N | N | N | C | C | C |
| C | C | N | C | C | C | C | C | C | C | C | N | N | N | C | C | C |
| C | N | N | C | C | N | N | N | N | C | N | N | N | N | C | C | C |
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| N | C | N | C | C | N | N | N | N | C | Q | N | N | N | C | C | C |
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| C | C | N | C | C | C | C | C | C | C | C | N | N | N | C | C | C |
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| AARP MedicareRx Saver Plus (PDP) S5921-353 | Cigna Secure Rx (PDP) S5617-217 | Clear Spring Health Value Rx (PDP) S6946-005 | Elixir RxSecure (PDP) S7694-008 | Exemplar Health Basic (PDP) S9325-002 | Humana Basic Rx Plan (PDP) S5884-133 | SilverScript Choice (PDP) S5601-016 | WellCare Classic (PDP) S4802-081 | WellCare Medicare Rx Saver (PDP) S5810-042 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Advantage (HMO I-SNP) H6351-001 | Liberty at Home (HMO I-SNP) H6351-003 | Longevity Health Plan (HMO I-SNP) H5374-001 | PruittHealth Premier (HMO I-SNP) H6345-001 | UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP) H5253-043 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5253-042 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-034 |
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| P | QP | N | C | C | QP | P | P | P | P | QP | N | N | N | P | P | P |
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| Q | Q | N | Q | Q | C | Q | Q | Q | Q | C | N | N | N | Q | Q | Q |
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