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) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | 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 | P | P | N | P | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | Q | N | N | Q | N | N | N | N | N |
| N | N | N | N | Q | Q | N | N | Q | 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 | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | 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 | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | Q | Q | N | Q | N | N | N | N | N |
| N | Q | N | 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 | P | N | N | QP | QP | 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 | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | 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 | QP | QP | QP | 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 | 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 | Q | N | N | N | N | N |
| N | N | N | N | N | N | N | N | Q | N | N | N | N | N |
| N | C | N | N | Q | Q | Q | N | N | N | N | N | N | N |
| N | C | N | N | C | C | Q | N | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | N | N | P | C | C | N | C | N | N | N | N | N |
| N | C | N | N | 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 | C | N | N | C | Q | Q | N | Q | N | N | N | N | N |
| N | N | 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 | C | N | N | N | N | N | N | N | 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 | N | N | N | N | 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 S | N | N | N | N | N | N | N | N |
| N | C | N | N | C | P | C | N | C | 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 | N | C | N | N | N | N | N |
| N | C | N | N | C | 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 | N | N | N | N |
| N | N | N | N | 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) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | Q | N | N | Q | Q | Q | N | C | N | N | N | N | N |
| N | C | N | N | C | Q | N | N | C S | 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 | C | N | N | C | C | Q | N | C | N | N | N | N | N |
| N | Q | N | N | Q | Q | Q | N | N | N | N | N | N | N |
| N | C | N | N | 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 | QP | N | N | QP | Q | Q | 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 | N | 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 |
| N | N | N | N | N | N | N | N | 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 | N | N |
| N | N | N | N | Q 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 | C | 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 | C | 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 | C | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | Q | 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 | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | 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 | Q | N | N | 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 | C | N | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | N | N | N | 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 | N | 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 | QP | Q | N | Q | N | N | N | N | N |
| N | N | N | N | N | N | C | N | C | N | N | N | N | N |
| N | 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 | Q | N | N | N | N | N | N | N | N |
| N | N | N | N | N | C | Q | N | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | N | N | P | P | QP | 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 | C | N | N | C | C | Q | N | C | N | N | N | N | N |
| N | P | N | N | QP | Q | QP | N | P | N | N | N | N | N |
| N | N | N | N | P | Q | 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 | C | N | N | N | C | Q | N | Q | N | N | N | N | N |
| 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 | C | N | N | C | C | N | N | C | N | N | N | N | N |
| N | N | N | N | C | C | C | N | C | N | N | N | N | N |
| N | N | N | N | C | C | C | N | C | N | N | N | N | N |
| N | N | N | N | C | C | C | N | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | C | N | N | C | Q | Q | N | Q | N | N | N | N | N |
| N | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | N | N | P | P | QP | N | C | N | N | N | N | N |
| N | Q | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | N | N | C | Q | Q | N | Q | N | N | N | N | N |
| N | N | 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 | C | N | N | C | 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 | QP | N | N | QPS | 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 | C | 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 | P | N | N | QP | QP | QP | N | P | N | N | N | N | N |
| N | P | N | N | P | P | P | N | P | N | N | N | N | N |
| N | QP | N | N | QP | Q | Q | N | Q | N | N | N | N | N |
| N | P | N | N | P | C | C | 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 | N |
| N | N | N | N | N | N | N | N | N | N | N | N | 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 | Q | 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 | C | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | N | N | P | QP | P | 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 | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | Q | Q | N | Q | N | N | N | N | N |
| N | Q | N | 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 | N | N | N | N |
| N | C | N | N | C | Q | Q | N | QP | N | N | N | N | N |
| N | Q | N | N | Q | C | C | 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 | N |
| N | P | N | N | N | N | N | N | C | N | N | N | N | N |
| N | Q | N | N | Q | Q | 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 | N | N | N | N | N | N | N | N | N | N |
| N | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | N | N | QP | C | C | N | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-380 | Banner Medicare Simple Rx (PDP) S3147-001 | Blue MedicareRx Value (PDP) S6506-001 | Cigna Secure Rx (PDP) S5617-138 | Clear Spring Health Value Rx (PDP) S6946-023 | Elixir RxSecure (PDP) S7694-028 | Humana Basic Rx Plan (PDP) S5884-146 | SilverScript Choice (PDP) S5601-056 | Wellcare Classic (PDP) S4802-092 | Amerivantage Comfort (HMO I-SNP) H2593-003 | Amerivantage Comfort (HMO I-SNP) H2593-019 | Amerivantage Comfort Plus (HMO I-SNP) H1423-007 | Amerivantage Comfort Plus (HMO I-SNP) H1423-008 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-005 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | 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 | Q | C | QP | 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 | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | N | N | Q | Q | C | N | Q | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N |
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