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) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | Q | Q |
| N | N | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N |
| N | 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 | P | P |
| N | QP | N | QP | QP | QP | QP | QP | QP |
| N | Q | Q | Q | C | C | C | Q | Q |
| N | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N |
| N | QP | QP | N | 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 |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 | C | C | C | Q | Q |
| 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 | N | N | N | N | QP | QP |
| N | N | N | N | N | N | N | N | N |
| N | Q | Q | Q | C | C | C | Q | Q |
| N | C | C | Q | C | C | C | C | C |
| N | N | N | Q | N | N | N | N | N |
| N | P | 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 | C | 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 | 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 | C | Q | Q | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N |
| N | N | N | Q | C | C | C | N | N |
| N | C | C | C | P | P | P | P | P |
| N | N | N | N | N | N | N | N | N |
| N | C | C | C | C | C | C | C | C |
| N | C | 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 | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | C | N | N | C | C | C | C | C |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | Q | C | Q | C | C | C | C | C |
| N | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | 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 | C | C | Q | Q | Q | Q | Q | Q |
| N | Q | N | Q | C | C | C | Q | Q |
| N | C | N | Q S | C S | C S | C S | C S | C S |
| N | C | N | N | C | C | C | C | C |
| N | QP | QP | 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 | P | QP | N | N | N | QP | QP |
| 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 | C | N | C | C | C | C | C | C |
| N | C | N | C | C | C | C | C | C |
| N | C | N | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N |
| N | C | N | C | C | C | C | C | C |
| N | C | N | C | C | C | C | C | C |
| 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 | N | N | N | N | N | N | N | N |
| N | Q | Q | Q | QP | QP | QP | 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 | 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 | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | N | N | N | 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 | P | Q | Q | Q | Q | Q | Q | Q |
| N | N | C | C | N | N | N | C | C |
| N | N | N | N | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N |
| N | Q | N | Q | Q | Q | Q | Q | Q |
| N | N | C | Q | Q | Q | Q | C | C |
| N | N | N | N | N | N | N | N | N |
| N | P | P | QP | Q | Q | Q | QP | QP |
| 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 |
| N | P | P | QP | C | C | C | QP | QP |
| N | N | N | QP | C | C | C | 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 | C | 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 | C | C | N | C | C | C | C | C |
| N | N | N | C | N | N | N | N | N |
| N | N | N | C | N | N | N | N | N |
| N | N | C | C | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | Q | Q | Q | C | C | C | Q | Q |
| N | C | N | 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 | N | N | N |
| N | P | C | P | P | P | P | QP | QP |
| N | N | N | N | N | N | N | N | N |
| N | C | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | Q | Q | Q | N | N |
| N | N | N | N | N | N | N | N | N |
| N | Q | 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 | QP | Q | Q | Q | Q S | Q S |
| N | N | N | N | N | N | N | N | N |
| N | N | Q | 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 | P | P | QP | N | N | N | P | P |
| N | P | P | P | P | P | P | P | P |
| N | QP | Q | Q | Q S | Q S | Q S | Q | Q |
| N | P | P | C | C | C | C | C | C |
| N | N | N | N | 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 | N | N | N |
| N | N | Q | 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 | C | C | Q | C | C | C | Q | Q |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N |
| N | Q | Q | N | QP | QP | 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 | Q | C | C | C | Q | Q |
| N | N | Q | Q | N | N | N | C | C |
| N | Q | Q | Q S | 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 | Q | N | Q | N | N | N | N | N |
| N | C | QP | Q | C | C | C | C | C |
| N | Q | Q | C | 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 | N | N | N |
| N | P | C | N | C | C | C | C | C |
| N | Q | 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 | QP | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-006 | Mutual of Omaha Rx Plus (PDP) S7126-008 | Wellcare Classic (PDP) S4802-070 | Humana Together in Health (PPO I-SNP) H5216-243 | NHC Advantage (HMO I-SNP) H4172-001 | PruittHealth Premier (HMO I-SNP) H6345-002 | Senior Care (HMO I-SNP) H4172-003 | UHC Care Advantage SC-E001 (PPO I-SNP) H0710-068 | UHC Nursing Home Plan SC-F001 (PPO I-SNP) H0710-053 |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | 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 | QP | QP | QP | QP | P | P |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q S | 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 | Q | Q | C | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N |