Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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 | N | N | N | N | N | N | N | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | N | Q | Q | Q | N | N | N | N | N | N | N | N | N | N |
| Q | Q | N | N | Q | Q | Q | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | N | C | C | C | N | N | N | N | N | N | N | C | 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 | N | N | N | N | N | N | N | C | 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 | P | P | N | N | N | N | N | N | N | N | N | N |
| P | N | N | N | N | QP | QP | N | N | N | N | N | N | N | P | P | P |
| Q | Q | Q | N | Q | C | C | N | N | N | N | N | N | N | C S | C S | C S |
| Q | Q | Q | N | Q | Q | Q | N | N | N | N | N | N | N | C S | C S | C S |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | QP | N | N | QP | QP | QP | N | N | N | N | N | N | N | P | 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | 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 | P | P | P |
| N | N | N | 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 | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | P | P | P |
| N | N | N | N | Q | N | N | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | Q | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | N | N | C | C | N | N | N | N | N | N | N | N | N | N |
| C | C | Q | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| P | C | C | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| C | C | C | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | N | Q | Q | Q | N | N | N | N | N | N | N | C | C | C |
| N | N | P | N | N | N | N | N | N | N | N | N | N | N | P | P | P |
| 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 | N | N | N | N | N | N | N | N | N | P | 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 |
| C | Q S | N | N | N | N | C | N | N | N | N | N | N | N | N | N | N |
| C | P | C | N | C | P | P | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | C | C | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| C | Q | Q | N | Q | Q | Q | N | N | N | N | N | N | N | C | 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 | N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
| Q | Q | Q | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| C | Q | N | N | C S | C | C | N | N | N | N | N | N | N | C S | C S | C S |
| N | N | N | 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 | 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 | N | N | N | N | N | N | N | C | C | C |
| Q | Q | Q | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| C | N | N | N | N | C S | C S | N | N | N | N | N | N | N | C S | C S | C S |
| N | N | N | N | N | C | C | N | N | N | N | N | N | N | Q | Q | Q |
| QP | Q | Q | N | QP | Q | Q | N | N | N | N | N | N | 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 | 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 | QP | N | P | Q | Q | N | N | N | N | N | N | N | P | P | P |
| N | N | N | 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 |
| Q S | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | C | C | C |
| Q | Q | N | N | P | Q | Q | N | N | N | N | N | N | N | C | 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 |
| Q | Q | Q | N | Q | QP | QP | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | N | C | C | C | N | N | N | N | N | N | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | Q | Q | N | Q | C | C | N | N | N | N | N | N | N | C | 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 | C | C | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
| C | C | C | N | C | 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 |
| P | QP | Q | N | Q | P | C | N | N | N | N | N | N | N | C | C | C |
| N | N | C | N | C | 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 |
| N | N | N | N | N | N | N | N | N | N | N | 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 | C | N | N | N | N | N | N | N | C | C | C |
| N | C | Q | N | C | Q | Q | N | N | N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | P | QP | N | P | Q | Q | N | N | N | N | N | N | N | P | 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 |
| C | C | Q | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| QP | Q | QP | N | P | C | C | N | N | N | N | N | N | N | C | C | C |
| P | Q | QP | N | N | C | C | N | N | N | N | N | N | N | C | 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 | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | Q | N | Q | C | C | N | N | N | N | N | N | N | C | C | C |
| P | 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 |
| C | C | N | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| C | C | C | N | C | C | P | N | N | N | N | N | N | N | N | N | N |
| C | C | C | N | C | C | C | N | N | N | N | N | N | N | N | N | N |
| C | C | C | N | C | 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 |
| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
| C | Q | Q | N | Q | C | C | N | N | N | N | N | N | N | C | C | C |
| C | C | N | N | N | C | C | N | N | N | N | N | N | N | C | 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 |
| P | P | QP | N | C | P | P | N | N | N | N | N | N | N | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | Q | Q | N | Q | Q | Q | N | N | N | N | N | N | N | C | C | C |
| 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 | C | C | N | N | N | N | N | N | N | C | 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 |
| QPS | N | QP | N | N | Q | Q | N | N | N | N | N | N | N | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | Q | N | Q | N | C | N | N | N | N | N | N | N | C | 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 |
| QP | QP | QP | N | P | N | N | N | N | N | N | N | N | N | P | P | P |
| P | P | P | N | P | P | P | N | N | N | N | N | N | N | P | P | P |
| QP | Q | Q | N | Q | QP | QP | N | N | N | N | N | N | N | P | P | P |
| P | C | C | N | P | C | C | N | N | N | N | N | N | N | P | P | P |
| N | N | N | N | N | C | C | N | N | N | N | N | N | N | P | 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 | N | N | N | N | N | N | N | N | N | P | P | P |
| 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 | C | C | N | N | N | N | N | N | N | C S | C S | C S |
| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | QP | P | N | QP | QP | QP | N | N | N | N | N | N | N | Q | Q | Q |
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| Q | N | N | N | N | C | C | N | N | N | N | N | N | N | C S | C S | C S |
| Q | Q | Q | N | Q | QP | QP | N | N | N | N | N | N | N | C | C | C |
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| C | Q | Q | N | QP | C | C | N | N | N | N | N | N | N | C | C | C |
| Q | C | C | N | Q | C | C | N | N | N | N | N | N | N | C | C | C |
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| N | N | N | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
| Q | Q | C | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
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| C | C | N | N | N | Q | Q | N | N | N | N | N | N | N | N | N | N |
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| QP | C | C | N | C | C | C | N | N | N | N | N | N | N | C | C | C |
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| Clear Spring Health Value Rx (PDP) S6946-027 | Elixir RxSecure (PDP) S7694-032 | Humana Basic Rx Plan (PDP) S5884-114 | SilverScript Choice (PDP) S5601-064 | Wellcare Classic (PDP) S4802-094 | Align Premier (HMO I-SNP) H3274-001 | Align Thrive (HMO I-SNP) H3274-002 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-005 | Anthem MediBlue Care On Site (HMO I-SNP) H0544-050 | Anthem MediBlue Care To You (HMO I-SNP) H0544-093 | Brand New Day Select Care I Plan (HMO I-SNP) H0838-042 | Brand New Day Select Care II Plan (HMO I-SNP) H0838-043 | Brand New Day Select Choice I Plan (HMO I-SNP) H0838-044 | Brand New Day Select Choice II Plan (HMO I-SNP) H0838-045 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Healthy at Home (HMO I-SNP) H9104-006 |
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| Q | C | QP | N | P | QP | QP | N | N | N | N | N | N | N | P | P | P |
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| N | N | N | N | N | Q S | Q S | N | N | N | N | N | N | N | N | N | N |
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