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) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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 | 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 | Q | Q | N | N | Q | Q | N | N | N | Q | N | N | N | N |
| N | N | Q | Q | N | N | Q | Q | 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 | C | C | Q | N | C | C | 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 | C | 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 | P | N | N | N | P | N | N | N | N |
| N | N | P | N | N | N | N | QP | N | N | N | QP | N | N | N | N |
| N | N | Q | Q | Q | N | Q | C | N | N | N | C | N | N | N | N |
| N | N | Q | Q | Q | N | Q | Q | 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 | QP | QP | N | N | QP | QP | 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | 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) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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 | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | Q | 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 | 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 | Q | Q | Q | N | N | C | N | N | N | C | N | N | N | N |
| N | N | C | C | Q | N | C | C | 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 | P | C | C | N | C | C | N | N | N | C | N | N | N | N |
| N | N | C | C | C | N | C | C | 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 | Q | Q | N | Q | Q | N | N | N | Q | 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 | C | N | N | 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 | N | N | N | N | N | N |
| N | N | C | Q S | N | N | N | C | N | N | N | N | N | N | N | N |
| N | N | C | P | C | N | C | P | 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 | C | C | N | C | C | N | N | N | C | N | N | N | N |
| N | N | C | Q | Q | N | Q | Q | 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 | N | 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 | P | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
| N | N | Q | Q | Q | N | C | C | N | N | N | C | N | N | N | N |
| N | N | C | Q | N | N | C S | C | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | Q | 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 | C | Q | N | C | Q | N | N | N | Q | N | N | N | N |
| N | N | Q | Q | Q | N | N | N | N | N | N | N | N | N | N | N |
| N | N | C | N | N | N | N | C S | N | N | N | C S | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | C | N | N | N | N |
| N | N | QP | Q | Q | N | QP | Q | 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 | 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 | QP | N | P | Q | N | N | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | N | N | N | C | N | N | N | N |
| N | N | Q S | 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 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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 | Q | 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 | 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 | QP | 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 | Q | Q | Q | N | C | C | 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 | Q | Q | Q | N | Q | C | 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 | C | N | N | N | 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) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
| N | N | C | C | C | N | C | C | 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 | Q | N | Q | C | N | N | N | P | N | N | N | N |
| N | N | N | N | C | N | C | C | N | N | N | C | N | N | N | N |
| N | N | C | C | N | N | N | C | 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 | Q | N | N | N | C | N | N | N | C | N | N | N | N |
| N | N | N | C | Q | N | C | Q | 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 | P | P | QP | N | P | Q | 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 | C | Q | N | C | C | N | N | N | C | N | N | N | N |
| N | N | QP | Q | QP | N | P | C | N | N | N | C | N | N | N | N |
| N | N | P | Q | QP | N | N | C | 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 | C | Q | N | Q | C | N | N | N | C | 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 | C | 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 | C | N | N | C | C | N | N | N | C | N | N | N | N |
| N | N | C | C | C | N | C | P | N | N | N | C | N | N | N | N |
| N | N | C | C | C | N | C | C | N | N | N | C | N | N | N | N |
| N | N | C | C | C | N | C | C | N | N | N | 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) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
| N | N | C | Q | Q | N | Q | C | N | N | N | C | N | N | N | N |
| N | N | C | C | N | N | N | C | 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 | P | P | QP | N | C | P | 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 | Q | Q | N | Q | Q | N | N | N | Q | 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 | N | N | N | N | N |
| N | N | C | Q | Q | N | C | C | 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 | QPS | N | QP | N | N | Q | 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 | C | N | Q | N | Q | 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 | QP | QP | QP | N | P | N | N | N | N | N | N | N | N | N |
| N | N | P | P | P | N | P | P | N | N | N | P | N | N | N | N |
| N | N | QP | Q | Q | N | Q | QP | N | N | N | QP | N | N | N | N |
| N | N | P | C | C | N | P | C | N | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | C | 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 | 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 | Q | Q | Q | N | C | C | N | N | N | C | N | N | N | N |
| AARP MedicareRx Saver Plus (PDP) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | P | QP | P | N | QP | QP | 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 | N | 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 | N | N | N | C | N | N | N | N |
| N | N | Q | Q | Q | N | Q | QP | N | N | N | QP | N | N | N | N |
| N | N | Q | Q | Q | N | Q | C | 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 |
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| AARP MedicareRx Saver Plus (PDP) S5921-352 | Cigna Secure Rx (PDP) S5617-216 | Clear Spring Health Value Rx (PDP) S6946-004 | Elixir RxSecure (PDP) S7694-007 | Humana Basic Rx Plan (PDP) S5884-132 | SilverScript Choice (PDP) S5601-014 | Wellcare Classic (PDP) S4802-069 | Align Thrive (HMO I-SNP) H1277-001 | Anthem MediBlue Care on Site (HMO I-SNP) H3447-010 | Anthem MediBlue Care To You (HMO I-SNP) H3447-026 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | LifeWorks Advantage I-SNP (HMO I-SNP) H2185-001 | UnitedHealthcare Assisted Living Plan (PPO I-SNP) H0710-059 | UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) H5322-001 | UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) H2228-010 | UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) H0710-032 |
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