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) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | Q | N | Q | N | N | N | Q | Q | Q | Q |
| N | N | Q | Q | Q | Q | C | C | Q | Q | Q | Q | Q |
| 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 | 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 | P | N | P | N | N | N | P | P | P | P |
| N | N | N | QP | QP | QP | N | N | QP | QP | QP | QP | QP |
| N | Q | Q | Q | C | Q | Q | Q | C | 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 | N | QP | QP | QP | 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) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | Q | C | QP | P | P | C | Q | Q | Q | Q |
| N | N | N | N | Q | N | 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 | QP | N | QP | N | N | N | QP | QP | QP | QP |
| N | N | N | N | N | C | N | N | N | N | N | N | N |
| N | Q | Q | Q | C | C | C | C | C | Q | Q | Q | Q |
| N | Q | 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 | 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 | Q | C | C | C | C | C | 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 | QP | N | 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 | Q | Q | N | C | C | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | C | N | C | C | C | N | N | N | N |
| N | C | C | P | P | C | C | C | P | P | P | P | P |
| 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 | Q | Q | Q | Q | C | C | C | 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 |
| Clear Spring Health Value Rx (PDP) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | N | N | C | C | C | C | C | C | C | C | C | C |
| Clear Spring Health Value Rx (PDP) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | Q | C | C | C | Q | C | C | C | C | C | C | C |
| N | N | Q | Q | C | Q | C | C | Q | Q | Q | Q | Q |
| N | N | N | Q | Q | N | N | N | 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 | Q | C | Q | Q | C | C | C | Q | Q | Q | Q | Q |
| N | Q | N | Q | C | Q | C | C | C | Q | Q | Q | Q |
| N | N | N | C S | C S | C | C | C | C S | C S | C S | C S | C S |
| N | N | N | C | C | C | C | C | C | C | C | C | C |
| N | Q | QP | Q | Q | QP | QP | QP | 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 | QP | P | QP | N | QP | N | N | N | QP | QP | QP | QP |
| 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | C | N | N | N | N | N | N | N |
| N | N | N | C | C | C | N | N | C | C | C | C | C |
| N | N | N | C | C | C S | N | N | C | C | C | C | C |
| N | N | N | C | C | C | N | N | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | C | C | C | N | N | C | C | C | C | C |
| N | N | N | C | C | C | N | N | C | C | C | C | C |
| N | Q | Q | Q | Q | Q | C | C | Q | Q | Q | Q | Q |
| 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 | C | C | N | N | N | N | N |
| N | N | N | N | N | N | C | C | N | N | N | N | N |
| N | Q | Q | C | Q | Q | Q | Q | QP | 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 | Q | Q | C | C | C | C | C | 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 | C | Q | N | N | C | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | N | N | C | C | C S | 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 | Q | Q | C | C | P | P | Q | Q | Q | Q | Q |
| N | C | C | C | N | C | N | N | N | C | C | C | C |
| N | N | N | 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 | N | Q | Q | Q | C | C | Q | Q | Q | Q | Q |
| N | Q | C | C | Q | C | C | C | Q | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | QP | P | QP | Q | P | P | P | Q | 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 | Q | Q | C | C | Q | C | C | C | C | C | C | C |
| N | QP | P | QP | C | P | C | C | C | QP | QP | QP | QP |
| N | QP | N | QP | C | P | C | C | C | 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 | 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 | Q | Q | C | C | C | C | C | Q | Q | Q | Q |
| 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 | N | N | N | N |
| N | N | C | C | C | C | C | C | C | C | C | C | C |
| N | C | N | N | N | N | C | C | N | N | N | N | N |
| N | C | N | N | N | N | C | C | 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 |
| Clear Spring Health Value Rx (PDP) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | Q | Q | Q | C | C | C | C | C | Q | Q | Q | Q |
| N | Q | N | Q | C | C | C | C | C | 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 | P | C | QP | P | P | P | P | P | QP | QP | QP | QP |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | Q | Q | C | C | C | Q | Q | Q | Q | Q |
| 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 | Q | Q | Q | C | Q | C | C | C | 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 | QP | N | Q S | Q | QP | C | C | Q | Q S | Q S | Q S | Q S |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | 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 | N | N |
| N | N | N | N | N | Q | N | N | N | N | N | N | N |
| N | QP | P | P | N | P | N | N | N | P | P | P | P |
| N | P | P | P | P | P | P | P | P | P | P | P | P |
| N | Q | Q | Q | Q S | QP | C | C | Q S | Q | Q | Q | Q |
| N | C | P | C | C | P | C | C | C | C | C | C | C |
| N | N | N | Q | C | C | C | C | C | 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 | Q | N | N | Q | N | N | N | N | N | N | N |
| N | N | Q | N | N | Q | 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 | C | C | C | Q | Q | Q | Q |
| Clear Spring Health Value Rx (PDP) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | Q | P | QP | Q | P | P | QP | 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 | Q | C | Q | C | C | C | Q | Q | Q | Q |
| N | Q | Q | C | N | Q | Q | Q | N | C | C | C | C |
| N | Q S | Q | C | C | Q | Q | Q | 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 | N | N | N | Q | N | N | N | N | N | N | N |
| N | Q | QP | C | C | C | C | C | C | C | C | C | C |
| N | C | Q | Q | C | Q | C | C | C | 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 | C | C | C | C | N | N | C | C | C | C | C |
| N | C | C | C | C | Q | C | C | C | C | C | C | C |
| 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 | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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) S6946-005 | Humana Basic Rx Plan (PDP) S5884-133 | Wellcare Classic (PDP) S4802-081 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) H6351-001 | Longevity Health Plan (HMO I-SNP) H5374-001 | Provider Partners North Carolina Advantage Plan (HMO I-SNP) H4439-001 | Provider Partners North Carolina Community Plan (HMO I-SNP) H4439-002 | PruittHealth Premier (HMO I-SNP) H6345-001 | UHC Care Advantage NC-E001 (HMO-POS I-SNP) H5253-043 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan NC-F001 (PPO I-SNP) H0710-034 | UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP) H5253-042 |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | 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 | Q | C | C | QP | P | P | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q S | N | N | N | Q S | N | N | N | N |
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| N | C | Q | Q | C | Q | Q | Q | C | Q | Q | Q | Q |
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| N | N | N | N | N | C | N | N | N | N | N | N | N |
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| N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N |