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) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | 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 | N | 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 | Q | Q | N | N | Q | Q | Q | Q | N | N | C | C | N | N | N |
| N | N | Q | Q | N | N | Q | Q | Q | Q | 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 | C | C | Q | N | C | Q | Q | 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 | 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 | P | N | N | N | N | N | N | N |
| N | N | P | N | N | N | N | QP | QP | P | N | N | N | N | N | N | N |
| N | N | Q | Q | Q | N | Q | Q | Q | Q | N | N | QP | QP | N | N | N |
| N | N | Q | Q | Q | N | Q | Q | Q | Q | 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 | QP | QP | N | N | QP | N | N | P | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | 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 | QP | N | QP | QP | QP | QP | N | N | P | P | 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 | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | QP | QP | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | Q | N | N | QP | N | N | N | N | N | N | N |
| N | N | N | N | N | N | Q | N | N | C | N | N | N | N | N | N | N |
| N | N | Q | Q | Q | N | N | Q | Q | C | N | N | C | C | N | N | N |
| N | N | C | C | Q | N | C | Q | Q | C | N | N | C | C | N | N | N |
| N | N | N | N | N | N | N | Q | Q | N | N | N | N | N | N | N | N |
| N | N | P | C | C | N | C | C | C | C | N | N | C | C | N | N | N |
| N | N | C | C | C | N | 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 | C | Q | Q | N | Q | Q | Q | C | N | N | C | C | N | N | N |
| N | N | N | N | 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 | C | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | QP | QP | QP | N | N | QP | QP | N | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | Q S | N | N | N | Q S | Q S | N | N | N | C | C | N | N | N |
| N | N | C | P | C | N | 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 | C | C | C | N | C | C | C | C | N | N | C | C | N | N | N |
| N | N | C | Q | Q | N | Q | Q | Q | 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 | 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) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
| N | N | Q | Q | Q | N | C | Q | Q | Q | N | N | C | C | N | N | N |
| N | N | C | Q | N | N | C S | Q | Q | 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 | C | C | Q | N | C | Q | Q | C | N | N | C | C | N | N | N |
| N | N | Q | Q | Q | N | N | Q | Q | Q | N | N | C | C | N | N | N |
| N | N | C | N | N | N | N | N | N | C | N | N | P | P | N | N | N |
| N | N | N | N | N | N | N | N | N | C | N | N | C | C | N | N | N |
| N | N | QP | Q | Q | N | QP | Q | Q | 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 | 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 | Q S | N | N | N | N | N | N | C | N | N | N | N | N | N | N |
| N | N | Q S | 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 | 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 | N | N | N | N | C | N | N | N | N | N | N | N |
| N | N | Q | Q | N | N | P | Q | Q | Q | 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 | C | C | N | N | N | C | C | N | N | N |
| N | N | N | N | N | N | N | C | C | N | N | N | C | C | N | N | N |
| N | N | N | N | N | N | N | C | C | N | N | N | C | C | N | N | N |
| N | N | Q | Q | Q | N | 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 | Q | Q | Q | N | C | Q | Q | Q | 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 | Q | Q | Q | N | Q | Q | Q | C | N | N | C | C | 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 | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | Q | N | N | C | C | 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) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
| N | N | C | C | C | N | C | C | C | C S | 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 | P | QP | Q | N | Q | Q | Q | C | N | N | P | P | N | N | N |
| N | N | N | N | C | N | C | C | C | C | N | N | N | N | N | N | N |
| N | N | C | C | 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 | Q | N | N | N | N | N | Q | N | N | C | C | N | N | N |
| N | N | N | C | Q | N | C | Q | Q | 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 | P | P | QP | N | P | QP | QP | 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 | C | C | Q | N | C | Q | Q | C | N | N | C | C | N | N | N |
| N | N | QP | Q | QP | N | P | QP | QP | P | N | N | C | C | N | N | N |
| N | N | P | Q | QP | N | N | QP | QP | P | 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 | 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 | C | Q | N | Q | Q | Q | C | N | N | C | C | N | N | N |
| N | N | P | 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 | N | N | N |
| N | N | C | C | N | N | C | N | N | C | N | N | C | C | N | N | N |
| N | N | C | C | C | N | C | C | C | N | N | N | C | C | N | N | N |
| N | N | C | C | C | N | C | C | C | N | N | N | C | C | N | N | N |
| N | N | C | C | C | N | C | C | C | N | N | N | C | C | 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) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
| N | N | C | Q | Q | N | Q | Q | Q | C | N | N | C | C | N | N | N |
| N | N | C | C | N | N | N | Q | Q | 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 | N | N | N | N | N | N |
| N | N | P | P | QP | N | C | QP | QP | C | N | N | P | P | N | N | N |
| N | N | N | N | N | N | N | Q | Q | N | N | N | N | N | N | N | N |
| N | N | C | Q | Q | N | Q | Q | Q | C | N | N | C | C | 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 | N | N | N | N | N | N | N |
| N | N | C | Q | Q | N | C | Q | Q | 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 | QPS | N | QP | N | N | QP | QP | QP | 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 | C | N | 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 | Q | N | N | N | N | N | N | N |
| N | N | QP | QP | QP | N | P | QP | QP | P | N | N | N | N | N | N | N |
| N | N | P | P | P | N | P | P | P | P | N | N | P | P | N | N | N |
| N | N | QP | Q | Q | N | Q | Q | Q | QP | N | N | C | C | N | N | N |
| N | N | P | C | C | N | P | C | C | P | N | N | C | C | 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 | 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 | 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 | Q | Q | Q | N | C | Q | Q | C | N | N | C | C | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
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| AARP MedicareRx Saver Plus (PDP) S5921-362 | Cigna Secure Rx (PDP) S5617-224 | Clear Spring Health Value Rx (PDP) S6946-014 | Elixir RxSecure (PDP) S7694-017 | Humana Basic Rx Plan (PDP) S5884-107 | SilverScript Choice (PDP) S5601-034 | Wellcare Classic (PDP) S4802-087 | Humana Together in Health I-SNP (HMO I-SNP) H1468-019 | Humana Together in Health IE-SNP (HMO I-SNP) H1468-020 | Longevity Health Plan (HMO I-SNP) H9590-001 | MoreCare At Home (HMO I-SNP) H2678-004 | MoreCare Home (HMO I-SNP) H2678-003 | Provider Partners Illinois Advantage Plan (HMO I-SNP) H3800-001 | Provider Partners Illinois Community Plan (HMO I-SNP) H3800-002 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-055 | UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP) H2802-027 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-039 |
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