|
Longevity Health Plan (HMO I-SNP)
|
Tier 1 - Preferred Generic |
— |
— |
—
|
None |
|
PruittHealth Premier (HMO I-SNP)
|
Tier 1 - Preferred Generic |
— |
— |
—
|
None |
|
NHC Advantage (HMO I-SNP)
|
Tier 1 - Preferred Generic |
— |
— |
—
|
None |
|
Senior Care (HMO I-SNP)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
Wellcare Simple Open (PPO)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
Wellcare Simple (HMO-POS)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
Wellcare Giveback Open (PPO)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
Troy Medicare (HMO)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
Tier 2 - Generic |
— |
— |
—
|
None |
|
HealthSpring Preferred Select (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HealthSpring Preferred Plus (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HealthSpring TotalCare (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HealthSpring TotalCare Plus (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HealthSpring Preferred (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HealthSpring Preferred Savings (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
DEVOTED CORE 001 NC (HMO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
DEVOTED GIVEBACK 002 NC (HMO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
DEVOTED GIVEBACK 012 NC (HMO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
Humana Gold Plus H6622-057 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus H6622-060 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus H6622-061 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Choice H8145-004 (PFFS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Wellcare Dual Liberty Open (PPO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Wellcare Assist Open (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Wellcare Dual Access (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Wellcare Dual Liberty (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
Erickson Advantage Liberty (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
Erickson Advantage Freedom (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
Erickson Advantage Signature (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
Humana Gold Plus H1036-137 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus H1036-233 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Dual Select H1036-307 (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus H1036-335 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice Giveback H5216-017 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice H5216-211 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Full Access H5525-034 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice Giveback H5525-035 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice H5525-049 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice H5525-050 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice H5525-070 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Dual Select H5525-072 (PPO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
HumanaChoice H5525-083 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus H6622-025 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Gold Plus H6622-026 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |
|
Erickson Advantage Champion (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
✓ |
— |
—
|
PA |
|
HealthSpring True Choice (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
—
|
None |