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) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| 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 | N | P | P | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | N | N | Q | N | C | C | N |
| N | N | Q | Q | N | N | Q | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | C | Q | N | C | 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 | P | N | N | N | N | N | N | N | N |
| N | N | Q | Q | Q | N | Q | N | QP | QP | N |
| N | N | Q | Q | Q | N | Q | N | QP | QP | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | QP | QP | N | N | QP | 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 |
| AARP MedicareRx Saver Plus (PDP) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| 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 | N | P | P | 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 | N | N |
| N | N | N | N | N | N | Q | N | N | N | N |
| N | N | Q | Q | Q | N | N | N | C | C | N |
| N | N | C | C | Q | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | C | C | N | C | N | C | C | N |
| N | N | C | C | C | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | Q | Q | N | Q | N | C | C | 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 | C | N | N | N | N | N | N | N | N |
| N | N | QP | 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 | C | Q S | N | N | N | N | C | C | N |
| N | N | C | P | C | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | C | C | N | C | N | C | C | N |
| N | N | C | Q | Q | N | Q | 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 |
| AARP MedicareRx Saver Plus (PDP) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | Q | Q | Q | N | C | N | C | C | N |
| N | N | C | Q | N | N | C S | 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 | C | C | Q | N | C | N | C | C | N |
| N | N | Q | Q | Q | N | N | N | C | C | N |
| N | N | C | N | N | N | N | N | P | P | N |
| N | N | N | N | N | N | N | N | C | C | N |
| N | N | QP | Q | Q | N | QP | 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 | 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 | Q S | 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 | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| 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 | P | N | C | C | 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 | C | C | N |
| N | N | N | N | N | N | N | N | C | C | N |
| N | N | Q | Q | Q | N | Q | N | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | Q | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | Q | Q | N | Q | N | C | C | 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 | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | C | C | C | N | C | 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 | P | QP | Q | N | Q | N | P | P | N |
| N | N | N | N | C | N | C | N | N | N | N |
| N | N | C | C | 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 | Q | N | N | N | N | C | C | N |
| N | N | N | C | Q | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | P | QP | N | P | 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 | C | C | Q | N | C | N | C | C | N |
| N | N | QP | Q | QP | N | P | N | C | C | N |
| N | N | P | Q | QP | 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 | 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 | C | Q | N | Q | N | C | C | 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 | C | C | N | N | C | N | C | C | N |
| N | N | C | C | C | N | C | N | C | C | N |
| N | N | C | C | C | N | C | N | C | C | N |
| N | N | C | C | C | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | C | Q | Q | N | Q | N | C | C | N |
| N | N | C | C | 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 | P | P | QP | N | C | N | P | P | N |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | Q | Q | N | Q | N | C | C | 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 | C | Q | Q | N | C | 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 | QPS | N | QP | N | N | N | C | C | 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 | QP | QP | QP | N | P | N | N | N | N |
| N | N | P | P | P | N | P | N | P | P | N |
| N | N | QP | Q | Q | N | Q | N | C | C | N |
| N | N | P | C | C | N | P | N | C | C | 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 | 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 | Q | Q | Q | N | C | N | C | C | N |
| AARP MedicareRx Saver Plus (PDP) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | QP | P | N | QP | 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 | Q | N | N | N | N | N | C | C | N |
| N | N | Q | Q | Q | N | Q | N | Q | Q | N |
| N | N | Q | Q | Q | N | Q | 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 | C | Q | Q | N | QP | N | C | C | N |
| N | N | Q | C | C | N | Q | 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 | C | N | N | N | N |
| N | N | Q | Q | C | N | C | 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 | C | C | 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 | QP | C | C | N | C | N | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-351 | Cigna Secure Rx (PDP) S5617-215 | Clear Spring Health Value Rx (PDP) S6946-003 | Elixir RxSecure (PDP) S7694-006 | Humana Basic Rx Plan (PDP) S5884-104 | SilverScript Choice (PDP) S5601-012 | Wellcare Classic (PDP) S4802-080 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) H4093-001 | Provider Partners Pennsylvania Community Plan (HMO I-SNP) H4093-004 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-017 |
| N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N |
| 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 | QP | N | P | 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 | Q | Q | C | N | Q | 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 | 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 |