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) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | 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 |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | Q | Q |
| N | Q | Q | C | C | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | 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 | P | P |
| N | N | N | P | N | QP | QP | QP |
| N | Q | Q | C | Q | Q | Q | Q |
| N | Q | Q | C | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | QP | QP | QP | 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 |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | N | N | N | N | N | N | N |
| N | 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 | P | QP | Q | 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 | QP | N | N | N | N | QP | QP |
| N | N | N | N | N | N | N | N |
| N | Q | Q | C | C | Q | Q | Q |
| N | C | C | C | C | Q | C | C |
| N | Q | N | N | N | Q | N | N |
| N | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | Q | Q | C | C | 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 | QP | N | P | P | QP | 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 | N |
| N | N | N | N | N | N | N | N |
| N | N | N | C | C | Q | N | N |
| N | C | C | C | C | C | P | P |
| N | N | N | N | N | N | N | N |
| N | Q | C | C | C | C | C | C |
| N | Q | Q | C | C | 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 |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | C | N | C | C | N | C | C |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | Q | C | C | C | Q | C | C |
| N | N | Q | C | C | Q | Q | Q |
| N | N | N | Q | N | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | Q | N | N | N | N | N | N |
| N | C | C | C | C | Q | Q | Q |
| N | Q | N | C | C | Q | Q | Q |
| N | C S | N | C | C | Q S | C S | C S |
| N | C | N | C | C | N | C | C |
| N | QP | QP | QP | QP | 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 | P | 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 | C | C | C |
| N | N | N | N | N | C | C | C |
| N | N | N | N | N | C | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | C | C | C |
| N | N | N | N | N | C | C | C |
| N | Q | Q | C | C | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | C | C | N | N | N |
| N | N | N | C | C | N | N | N |
| N | N | N | C | C | N | N | N |
| N | Q | Q | C | Q | 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 | N | N |
| N | Q | Q | C | C | Q | Q | Q |
| 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 |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | N | N | C | 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 | QP | Q | C | P | Q | Q | Q |
| N | C | C | N | N | C | C | C |
| N | C | N | C | C | N | C | C |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | N | N | C | C | Q | Q | Q |
| N | C | C | C | C | Q | C | C |
| N | N | N | N | N | N | N | N |
| N | P | P | P | P | QP | QP | QP |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | C | Q | C | C | Q | C | C |
| N | QP | P | C | C | QP | QP | QP |
| N | QP | N | C | C | QP | QP | QP |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| 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 | Q | Q | C | C | 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 | C | C | C | C | N | C | C |
| N | N | N | C | C | C | N | N |
| N | N | N | C | C | C | N | N |
| N | C | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | Q | Q | C | C | Q | Q | Q |
| N | QP | N | C | C | 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 | P | C | C | P | P | QP | QP |
| N | N | N | N | N | N | N | N |
| N | Q | Q | C | C | Q | Q | Q |
| N | QP | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | Q | Q | C | C | Q | Q | Q |
| N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | N | N | C | C | QP | Q S | Q S |
| 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 | P | P | P | N | QP | P | P |
| N | P | P | P | P | P | P | P |
| N | Q | Q | C | C | Q | Q | Q |
| N | P | P | C | C | C | C | C |
| N | P | N | C | C | 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 | Q | N | N | N | N | N |
| N | N | Q | N | N | N | N | N |
| N | N | N | N | N | N | N | N |
| N | C | C | C | C | Q | Q | Q |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | N | N | N | N | N | N | N |
| N | QP | Q | P | 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 | Q | N | C | C | Q | Q | Q |
| N | Q | Q | C | Q | Q | C | C |
| N | Q | Q | C | Q | Q S | 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 | QP | QP | C | C | Q | C | C |
| N | Q | Q | C | C | C | 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 | C | C | N | N | N | C | C |
| N | 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 | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-012 | SilverScript Choice (PDP) S5601-030 | Wellcare Classic (PDP) S4802-086 | American Health Advantage of Indiana (HMO I-SNP) H9690-001 | CommuniCare Advantage ISNP (HMO I-SNP) H3727-002 | Humana Together in Health (PPO I-SNP) H5216-400 | UHC Care Advantage IN-E001 (PPO I-SNP) H0710-061 | UHC Nursing Home Plan IN-F001 (PPO I-SNP) H0710-013 |
| N | N | N | N | N | N | N | N |
| N | 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 | C | C | QP | 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 | Q | Q | C | Q | C | 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 |