Key
C | Covered - No restrictions |
Q | Has quantity limits |
S | Has step therapy |
P | Has prior authorization |
N | Not Covered |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| 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 | N | N | N | N | N | N | N | N | N |
| P | N | P | 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 |
| Q | N | Q | Q | Q | Q | Q | C | C | C | C | C | C | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | QP | QP | 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 | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | N | N | N | QP | QP | P | P | P | P | P | P | QP | QP |
| Q | N | Q | Q | Q | C | C | C | C | C | C | C | C | C | C |
| Q | N | Q | Q | Q | Q | Q | C | C | C | C | C | C | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | QP | QP | QP | QP | QP | P | P | P | P | P | P | 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 | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| 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 |
| QP | N | QP | QP | QP | C | C | P | P | P | P | P | P | C | C |
| N | N | N | N | N | Q | Q | N | 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 | P | P | P | P | P | P | N | N |
| N | N | N | QP | QP | N | N | C | C | C | C | C | C | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | C | C | C | C | C | C | C | C | C | C |
| N | N | C | N | N | C | C | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | C | C | C | C | C | C | N | N |
| P | N | C | 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 |
| Q | N | Q | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | 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 | QP | QP | N | N | 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 | Q | Q | Q | 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 | Q | Q | C | C | N | N | N | N | N | N | C | C |
| C | N | C | C | C | P | P | C | C | C | C | C | C | P | P |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | C | C | C | C | C | C | C | C | C | C | C | C |
| Q | N | Q | Q | Q | Q | Q | C | C | 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 | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| N | N | N | N | N | C | C | N | N | N | N | N | N | C | C |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| Q | N | C | Q | Q | C | C | C | C | C | C | C | C | C | C |
| N | N | Q | Q S | Q S | Q | Q | C | C | C | C | C | C | Q | Q |
| N | N | N | Q | Q | Q | Q | N | 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 |
| Q | N | C | C | C | Q | Q | C | C | C | C | C | C | Q | Q |
| Q | N | N | Q | Q | C | C | C | C | C | C | C | C | C | C |
| C S | N | N | N | N | C S | C S | C | C | C | C | C | C | C S | C S |
| C | N | N | N | N | C | C | C | C | C | C | C | C | C | C |
| Q | N | QP | QP | QP | 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 |
| N | N | N | N | 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 |
| QP | N | P | QP | QP | N | N | P | P | P | P | P | P | N | N |
| N | N | N | N | N | C | C | 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 |
| C | N | N | C | C | C | C | C | C | C | C | C | C | C | C |
| C | N | N | C | C | C | C | C | C | 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 |
| C | N | N | C | C | C | C | C | C | C | C | C | C | C | C |
| C | N | N | C | C | C | C | C | C | C | C | C | C | C | C |
| Q | N | Q | Q | Q | Q | Q | C | C | 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 | N | N | N | N | N | N |
| Q | N | Q | Q | Q | QP | QP | C | C | C | 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 |
| Q | N | Q | Q | Q | 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 | 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 |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| QP | N | Q | QP | QP | Q | Q | C | C | C | C | C | C | Q | Q |
| C | N | C | N | N | N | N | C | C | C | C | C | C | N | N |
| C | N | N | N | N | C | C | 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 | Q | Q | Q | Q | C | C | C | C | C | C | Q | Q |
| C | N | C | C | C | Q | Q | C | C | C | C | C | C | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | P | QP | QP | Q | Q | P | P | P | P | P | P | 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 | N | Q | C | C | C | C | C | C | C | C | C | C | C | C |
| QP | N | P | QP | QP | C | C | C | C | C | C | C | C | C | C |
| QP | N | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | 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 | 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 | C | 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 | 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 |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| C | N | Q | Q | Q | C | C | C | C | C | C | C | C | C | C |
| 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 | N | N | N |
| N | N | N | N | N | N | 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 | C | QP | QP | 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 |
| C | N | Q | Q | Q | Q | Q | C | C | C | C | C | C | Q | Q |
| N | N | N | N | N | Q | Q | N | N | N | N | N | N | Q | Q |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | 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 | QP | QP | 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 |
| N | N | Q | Q | Q | C | C | 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 |
| P | N | P | P | P | N | N | P | P | P | P | P | P | N | N |
| P | N | P | P | P | P | P | P | P | P | P | P | P | P | P |
| Q | N | Q | QP | QP | Q S | Q S | P | P | P | P | P | P | Q S | Q S |
| P | N | P | C | C | C | C | C | C | C | C | C | C | C | C |
| N | N | N | P | P | 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 | P | P | P | P | P | P | N | N |
| N | N | Q | 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 |
| Q | N | C | P | P | C | C | C | C | C | C | C | C | C | C |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| P | N | Q | N | N | QP | QP | Q | Q | Q | Q | Q | Q | 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 | C | C | C | C | C | C | C | C | C | C |
| Q | N | Q | Q | Q | N | N | C | C | C | C | C | C | N | N |
| Q | N | Q | Q | Q | QP | QP | C | C | C | 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 | N | N | N | N | N |
| Q | N | QP | Q | Q | C | C | C | C | C | C | C | C | C | C |
| Q | N | Q | Q | Q | 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 |
| P | N | C | C | C | C | C | C | C | C | C | C | C | C | C |
| C | N | C | 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 | N | N | N | N | N | N | N | N | N | N | N | N | N |
| C | N | C | 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 |
| Cigna Secure Rx (PDP) S5617-158 | Clear Spring Health Value Rx (PDP) S6946-027 | Wellcare Classic (PDP) S4802-094 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Anthem I Carelon Home Care (HMO I-SNP) H0544-005 | Premier Care (HMO I-SNP) H3274-002 | Premier Care (HMO I-SNP) H3274-002 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-086 | SCAN Embrace (HMO I-SNP) H5425-087 | SCAN Embrace (HMO I-SNP) H5425-091 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | SCAN Healthy at Home (HMO I-SNP) H9104-006 | Senior Care (HMO I-SNP) H3274-001 | Senior Care (HMO I-SNP) H3274-001 |
| 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 |
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| QP | N | QP | QP | QP | QP | QP | P | P | P | P | P | P | QP | QP |
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| N | N | N | N | N | Q S | Q S | N | N | N | N | N | N | Q S | Q S |
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| N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
| Q | N | Q | Q | Q | 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 | C | C | N | N | 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 |
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