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) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | N | N | Q | N | Q | N | N | N | N |
| N | N | Q | N | N | Q | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | Q | N | 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 | 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 | P | N | N | N | N |
| N | N | P | N | N | N | N | P | N | N | N | N |
| N | N | Q | Q | N | Q | N | Q | N | N | N | N |
| N | N | Q | Q | N | Q | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | QP | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| 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) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 | 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 | Q | N | QP | N | N | N | N |
| N | N | N | N | N | Q | N | C | N | N | N | N |
| N | N | Q | Q | N | N | N | C | N | N | N | N |
| N | N | C | Q | N | C | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | C | N | C | N | C | N | N | N | N |
| N | N | C | C | N | C | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | Q | N | Q | N | C | 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 | C | 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 | N | N | N | N | N | N |
| N | N | 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 | C | C | N | C | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | C | N | C | N | C | N | N | N | N |
| N | N | C | Q | N | 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 |
| AARP MedicareRx Saver Plus (PDP) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | Q | Q | N | C | N | Q | N | N | N | N |
| N | N | C | N | N | C S | 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 | Q | N | C | N | C | N | N | N | N |
| N | N | Q | Q | N | N | N | Q | N | N | N | N |
| N | N | C | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | QP | Q | N | 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 | QP | N | 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 | Q S | N | N | N | N | C | N | N | N | N |
| N | N | Q S | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | N |
| N | N | Q | N | N | P | 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 | Q | Q | N | Q | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | N | C | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | N | 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 | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | C | C | N | C | 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 | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | Q | N | Q | N | C | N | N | N | N |
| N | N | N | C | N | C | N | C | N | N | N | N |
| N | N | C | 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 | Q | N | N | N | N |
| N | N | N | Q | N | C | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | QP | N | P | 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 | C | Q | N | C | N | C | N | N | N | N |
| N | N | QP | QP | N | P | N | P | N | N | N | N |
| N | N | P | QP | 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 | N | N | N | N | N | N |
| N | N | N | 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 | N | C | N | N | N | N |
| N | N | P | 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 | C | N | N | C | N | C | 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 | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | C | Q | N | Q | N | C | N | N | N | N |
| N | N | C | 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 | P | QP | N | C | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | Q | N | Q | N | 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 | C | Q | N | 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 | QPS | QP | N | N | N | QP | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | 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 | Q | N | N | N | N |
| N | N | QP | QP | N | P | N | P | N | N | N | N |
| N | N | P | P | N | P | N | P | N | N | N | N |
| N | N | QP | Q | N | Q | N | QP | N | N | N | N |
| N | N | P | C | N | P | N | P | 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 | 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 | N | N |
| N | N | Q | Q | N | C | N | C | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | P | N | QP | 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 | Q | N | N | N | N | Q | N | N | N | N |
| N | N | Q | Q | N | Q | N | Q | N | N | N | N |
| N | N | Q | Q | 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 | C | Q | N | QP | N | C | N | N | N | N |
| N | N | Q | 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 | N | N | N | N |
| N | N | N | N | N | C | N | C | N | N | N | N |
| N | N | Q | C | N | C | N | Q | 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 | C | 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 | QP | C | N | C | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-349 | Cigna Secure Rx (PDP) S5617-018 | Clear Spring Health Value Rx (PDP) S6946-001 | Humana Basic Rx Plan (PDP) S5884-131 | SilverScript Choice (PDP) S5601-008 | Wellcare Classic (PDP) S4802-078 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Longevity Health Plan (PPO I-SNP) H9942-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-056 | UnitedHealthcare Nursing Home Plan (HMO I-SNP) H3113-001 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-003 | UnitedHealthcare Nursing Home Plan (PPO I-SNP) H0710-026 |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 | 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 | Q | 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 | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N |