Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Cigna Secure Rx (PDP) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | 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 | N | N | N | N | P | P | P | P | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | C | N | N | N | N | Q | C | C | C | N | N |
| N | Q | N | N | Q | C | N | N | N | N | Q | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | Q | N | C | C | N | N | N | N | 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 | 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 | N | N | N | N | N | P | N | N | N | N | N |
| N | N | N | N | N | P | N | N | N | N | QP | N | N | N | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | C | QP | QP | QP | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | Q | QP | QP | QP | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | N | N | QP | QP | N | N | N | N | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | 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) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | 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 | QP | N | QP | P | N | N | N | N | N | P | P | P | N | N |
| N | N | N | N | N | C | N | N | N | N | 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 | N | N | N | N |
| N | N | N | N | Q | 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 | Q | Q | N | N | C | N | N | N | N | C | C | C | C | N | N |
| N | C | Q | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | C | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | C | C | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | Q | C | C | C | N | 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 | QP | QP | N | N | P | N | N | 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 | Q S | N | N | N | C | N | N | N | N | N | C | C | C | N | N |
| N | P | C | N | C | C | N | N | N | N | P | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | C | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 |
| Cigna Secure Rx (PDP) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
| N | Q | Q | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | Q | N | N | C S | C | N | N | N | N | C | C | C | C | N | N |
| N | N | N | N | N | Q | 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 | C | Q | N | C | C | N | N | N | N | Q | C | C | C | N | N |
| N | Q | Q | N | N | C | N | N | N | N | N | C | C | C | N | N |
| N | N | N | N | N | C | N | N | N | N | C S | P | P | P | N | N |
| N | N | N | N | N | C | N | N | N | N | C | C | C | C | N | N |
| N | Q | Q | N | QP | QP | N | N | N | N | Q | 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 | QP | N | P | N | N | 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 | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | 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 | P | C | N | N | N | N | 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 | C | N | N | N | N | N | C | C | C | N | N |
| N | N | N | N | N | C | N | N | N | N | N | C | C | C | N | N |
| N | N | N | N | N | C | N | N | N | N | N | C | C | C | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | QP | Q | Q | Q | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | C | C | C | C | N | N |
| N | N | N | N | N | C | 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 | C | N | N | N | N | 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) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
| N | C | C | N | C | C | N | N | N | N | 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 | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | Q | N | Q | C | N | N | N | N | P | P | P | P | N | N |
| N | N | C | N | C | N | N | N | N | N | C | N | N | N | N | N |
| N | C | N | N | N | C | N | N | N | N | 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 | Q | N | N | N | C | N | N | N | N | C | C | C | C | N | N |
| N | C | Q | N | C | C | N | N | N | N | Q | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | QP | N | P | P | N | N | N | N | Q | 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 | C | Q | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | Q | QP | N | P | C | N | N | N | N | C | C | C | C | N | N |
| N | Q | QP | N | N | C | N | N | N | N | 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 | C | 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 | 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 | Q | C | N | N | N | N | 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 | C | 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 | N | N | N | C | C | C | C | N | N |
| N | C | C | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | C | C | N | C | C | N | N | N | N | C | C | C | C | N | N |
| N | C | C | N | C | C | N | N | N | N | 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) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
| N | Q | Q | N | Q | C | N | N | N | N | C | C | C | C | N | N |
| N | C | N | N | N | C | N | N | N | N | 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 | N | N | N | N | 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 | QP | N | C | P | N | N | N | N | P | P | P | P | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | Q | C | C | C | N | N |
| 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 | Q | Q | N | C | C | N | N | N | N | 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 | QP | N | N | C | N | N | N | N | Q | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | QP | N | P | P | N | N | N | N | N | N | N | N | N | N |
| N | P | P | N | P | P | N | N | N | N | P | P | P | P | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | QP | C | C | C | N | N |
| N | C | C | N | P | C | N | N | N | N | C | C | C | C | N | N |
| N | N | N | N | N | C | N | N | N | N | 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 | N | N | N | N | N | N | N | 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 | 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 | Q | Q | N | C | C | N | N | N | N | C | C | C | C | N | N |
| Cigna Secure Rx (PDP) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | P | N | QP | P | N | N | N | N | 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 | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | C | N | N | N | N | C | C | C | C | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | QP | Q | Q | Q | N | N |
| N | Q | Q | N | Q | C | N | N | N | N | C | 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 | Q | Q | N | QP | C | N | N | N | N | C | C | C | C | N | N |
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| Cigna Secure Rx (PDP) S5617-108 | Elixir RxSecure (PDP) S7694-022 | Humana Basic Rx Plan (PDP) S5884-143 | SilverScript Choice (PDP) S5601-044 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Amerivantage Comfort (HMO I-SNP) H2593-042 | Amerivantage Comfort Plus (HMO I-SNP) H8849-002 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Molina Medicare Comfort Care (HMO I-SNP) H7678-003 | ProCare Advantage (HMO I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Provider Partners Texas Community Plan (HMO I-SNP) H4054-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-058 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-020 |
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