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) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | P | P | P | P | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | Q | Q | Q | Q | Q | N |
| N | Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | P | P | P | P | P | P | P | P | 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 | P | P | P | P | P | N |
| N | N | N | N | QP | QP | QP | QP | QP | QP | QP | QP | N |
| N | Q | Q | Q | Q | C | C | Q | Q | Q | Q | Q | Q |
| N | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | QP | QP | N | QP | QP | QP | QP | QP | 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 | N | N | N | N |
| N | N | 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) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | P | QP | C | C | Q | Q | Q | Q | Q | P |
| N | N | N | C | N | Q | Q | 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 | QP | N | N | N | N | QP | QP | QP | QP | QP | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | C | Q | C | C | Q | Q | Q | Q | Q | C |
| N | C | C | C | Q | C | C | C | C | C | C | C | C |
| N | N | Q | N | Q | N | N | N | N | N | N | N | N |
| N | C | C | C | C | C | C | C | C | C | 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 | Q | Q | C | Q | C | C | Q | Q | Q | Q | 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 | QP | P | QP | 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 | Q | Q | N | Q | 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 | C | C | N | N | N | N | N | C |
| N | C | C | C | C | P | P | P | P | P | P | P | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | C | Q | C | C | C | C | C | C | C | C | C | C |
| N | Q | Q | C | Q | Q | Q | Q | Q | Q | Q | 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 | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | N | C | C | N | C | C | C | C | C | C | C | C |
| Clear Spring Health Value Rx (PDP) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | C | Q | C | Q | C | C | C | C | C | C | C | C |
| N | Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | N | N | N | Q | Q | Q | Q | Q | 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 | C | C | C | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | N | Q | C | Q | C | C | Q | Q | Q | Q | Q | C |
| N | N | C S | C | Q S | C S | C S | C S | C S | C S | C S | C S | C |
| N | N | C | C | N | C | C | C | C | C | C | C | C |
| N | QP | QP | QP | Q | Q | Q | Q | Q | Q | Q | Q | QP |
| 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 | P | N | N | QP | N | N | QP | QP | QP | QP | QP | N |
| N | N | N | N | N | C | C | 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 | C | C | C | C | C | C | C | C | N |
| N | N | N | N | C | C | C | C | C | C | C | C | N |
| N | N | N | N | C | C | C | C | C | C | C | C | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | C | C | C | C | C | C | C | C | N |
| N | N | N | N | C | C | C | C | C | C | C | C | N |
| N | Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | 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 | C |
| N | N | N | C | N | N | N | N | N | N | N | N | C |
| N | N | N | C | N | N | N | N | N | N | N | N | C |
| N | Q | Q | Q | Q | QP | QP | C | C | C | C | C | 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 | Q | Q | C | Q | C | C | Q | Q | Q | Q | 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 | C | N | N | C | C | 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) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | N | N | C | N | C | C | C | C | C | 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 | Q | QP | P | Q | Q | Q | Q | Q | Q | Q | Q | P |
| N | C | C | N | C | N | N | C | C | C | C | C | N |
| N | N | C | C | N | C | C | C | C | C | 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 | C | Q | Q | Q | Q | Q | Q | Q | Q | C |
| N | C | C | C | Q | Q | Q | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | P | P | P | QP | Q | Q | QP | QP | QP | QP | QP | 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 | Q | C | C | Q | C | C | C | C | C | C | C | C |
| N | P | QP | C | QP | C | C | QP | QP | QP | QP | QP | C |
| N | N | QP | C | QP | C | C | QP | QP | QP | QP | QP | 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 | Q | C | 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 | Q | Q | C | Q | C | C | Q | Q | Q | Q | 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 | C | C | C | N | C | C | C | C | C | C | C | C |
| N | N | C | C | C | N | N | N | N | N | N | N | C |
| N | N | C | C | C | N | N | N | N | N | N | N | C |
| N | C | C | C | C | N | N | N | N | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | Q | Q | C | Q | C | C | Q | Q | Q | Q | Q | C |
| N | N | QP | C | Q | C | C | Q | Q | Q | Q | 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 | C | P | P | P | P | P | QP | QP | QP | QP | QP | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | C | Q | Q | Q | Q | Q | Q | Q | Q | C |
| 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 | Q | Q | C | Q | C | C | Q | Q | Q | Q | 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 | C | QP | Q | Q | Q S | Q S | Q S | Q S | Q S | C |
| 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 | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | QP | N | N | P | P | P | P | P | N |
| N | P | P | P | P | P | P | P | P | P | P | P | P |
| N | Q | Q | C | Q | Q S | Q S | Q | Q | Q | Q | Q | C |
| N | P | P | C | C | C | C | C | C | C | C | C | C |
| N | N | P | C | N | C | C | Q | Q | Q | Q | 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 | Q | 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 | C | C | C | Q | C | C | Q | Q | Q | Q | Q | C |
| Clear Spring Health Value Rx (PDP) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | QP | P | N | QP | QP | P | P | P | 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 | Q | C | Q | C | C | Q | Q | Q | Q | Q | C |
| N | Q | Q | Q | Q | N | N | C | C | C | C | C | Q |
| N | Q | Q | Q | Q S | C | C | C | C | C | C | C | 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 | Q | N | N | N | N | N | N | N | N |
| N | QP | QP | C | Q | C | C | C | C | C | C | C | C |
| N | Q | Q | C | C | C | C | Q | Q | Q | Q | 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 | C | C | N | N | C | C | C | C | C | C | C | N |
| N | C | C | C | C | C | C | C | C | C | 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 | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-011 | Wellcare Classic (PDP) S4802-085 | Aetna Medicare Longevity Plan (HMO I-SNP) H0628-018 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-401 | Perennial Advantage Premier (HMO-POS I-SNP) H8797-004 | Perennial Advantage Strive (HMO I-SNP) H8797-001 | UHC Care Advantage OH-E001 (PPO I-SNP) H0710-057 | UHC Nursing Home Plan EX-F005 (PPO I-SNP) H2406-031 | UHC Nursing Home Plan OH-F001 (PPO I-SNP) H0710-027 | UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP) H5253-060 | UHC Nursing Home Plan OH-F003 (HMO-POS I-SNP) H5322-001 | Valor Health Plan (HMO I-SNP) H1119-001 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | P | C | QP | QP | QP | P | P | P | P | P | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | Q S | 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 | Q | Q | Q | C | C | C | Q | Q | Q | 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 | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |