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) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | 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 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | QP | N | N | N | N | N |
| N | Q | Q | N | Q | Q | Q | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N |
| N | 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 | P | N | N | N | N | N | P |
| N | N | QP | QP | QP | QP | N | N | N | QP |
| N | Q | C | Q | Q | Q | C | C | C | Q |
| N | Q | Q S | Q | Q | QP | Q S | Q S | Q S | Q |
| N | N | N | N | N | N | N | N | N | N |
| N | QP | 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 | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | 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 | QP | Q | QP | QP | QP | Q |
| N | N | Q | N | N | 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 | QP | N | N | N | N | N | QP |
| N | N | N | N | N | N | N | N | N | N |
| N | Q | C | C | Q | C | C | C | C | C |
| N | C | C | C | C | C | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| N | 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 | Q | Q | Q | Q | 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 | 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 | Q | Q | N | Q | Q | Q | Q | Q | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | Q | C | N | N | N | N |
| N | C | C | P | C | P | C | C | C | P |
| N | N | N | N | N | N | N | N | N | N |
| N | C | C | C | C | C | C | C | C | C |
| N | C | 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 | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | N | C | C | N | N | C | C | C | C |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | C | C | C | Q | Q | C | C | C | C |
| N | Q | Q S | Q | Q | Q | Q S | Q S | Q S | Q |
| 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 | C | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | Q | C | Q | N | Q | Q | Q | C |
| N | N | Q S | C S | Q S | C S | Q S | Q S | Q S | C S |
| N | N | N | C | N | C | N | N | N | C |
| N | QP | 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 | QP | QP | 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 | 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 | C |
| N | N | N | C | C | C | N | N | N | C |
| N | N | N | C | C | C | N | N | N | C |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | C | C | C | N | N | N | C |
| N | N | N | C | C | C | N | N | N | C |
| N | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | N | N | N | N | N |
| N | C | Q | N | N | N | Q | Q | Q | N |
| N | C | Q | N | N | N | Q | Q | Q | N |
| N | C | Q | N | N | N | Q | Q | Q | N |
| N | Q | Q | C | Q | QP | 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 | Q | C | C | 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 |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | 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 | Q | C | C | C | Q |
| N | N | Q | C | C | N | Q | Q | Q | C |
| N | N | Q | C | N | C | 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 | Q | Q | Q | Q | Q | Q | Q | Q |
| N | C | Q | C | Q | Q | Q | Q | Q | C |
| N | N | N | N | N | N | N | N | N | N |
| N | P | P | QP | QP | Q | P | P | P | QP |
| 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 |
| N | P | Q | QP | QP | Q | Q | Q | Q | QP |
| N | N | N | QP | QP | 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 | Q S | 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 |
| N | N | N | N | N | N | N | N | N | N |
| N | Q | C | Q | Q | 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 | C | N | C | N | C | N | N | N | C |
| N | N | N | N | C | N | N | N | N | N |
| N | N | N | N | C | 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 |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | Q | C | Q | Q | C | C | C | C | Q |
| N | N | Q S | Q | Q | C | Q S | Q S | Q S | 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 | C | C | QP | P | P | P | P | P | QP |
| N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | Q | Q | Q | Q | Q | Q | Q |
| N | N | N | N | N | Q | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | Q | Q S | Q | Q | C | Q S | Q S | Q S | Q |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | Q | Q | Q S | QP | Q | Q | Q | Q | 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |
| N | N | QP | P | N | N | N | N | N | P |
| N | P | P | P | P | P | P | P | P | P |
| N | Q | Q | Q | Q | Q S | Q | Q | Q | Q |
| N | P | C | C | C | C | C | C | C | C |
| N | N | C | Q | 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 | N | N | N | N |
| N | N | N | N | N | N | N | 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 | C | Q | Q | Q | Q |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N |
| N | Q | N | P | N | QP | 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 | Q | Q | C | N | N | N | Q |
| N | Q | N | N | Q | N | N | N | N | N |
| N | Q | C | C | Q S | Q | 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 | Q | N | N | N | N | N |
| N | QP | Q | C | Q | Q | Q | Q | Q | C |
| N | Q | Q | Q | 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 | C | C | C | N | C | C | C | C | C |
| N | 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 | Q | C | C | C | C | C | C | C | C |
| N | N | N | N | N | N | N | N | N | N |
| Clear Spring Health Value Rx (PDP) S6946-019 | Wellcare Classic (PDP) S4802-013 | American Health Advantage of Texas (HMO I-SNP) H6891-001 | Erickson Advantage Guardian (HMO-POS I-SNP) H5652-003 | Humana Together in Health (PPO I-SNP) H5216-369 | ProCare Advantage (HMO-POS I-SNP) H3467-001 | Provider Partners Texas Advantage Plan (HMO I-SNP) H4054-001 | Texas Independence Community Plan (HMO I-SNP) H5015-002 | Texas Independence Health Plan, Inc. (HMO I-SNP) H5015-001 | UHC Nursing Home Plan TX-F001 (PPO I-SNP) H0710-020 |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | 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 | QP | QP | QP | QP | P |
| N | N | N | N | N | N | N | N | N | N |
| N | N | N | N | N | 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 | Q | C | Q | 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 | N | N | N | N | N | N | N |
| N | N | N | N | N | N | N | N | N | N |