|
Aetna Medicare Signature (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Dual (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Value Plus (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Prime (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature Care (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Enhanced (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Enhanced (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Enhanced (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature Extra (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature Giveback (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Signature (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring True Choice (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring TotalCare (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring TotalCare Plus (HMO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring Preferred (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring Preferred Select (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring Preferred Savings (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
HealthSpring Preferred Plus (HMO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Aetna Medicare Chronic Care (HMO C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Erickson Advantage Signature (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Erickson Advantage Freedom (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Erickson Advantage Liberty (HMO-POS)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |
|
Erickson Advantage Champion (HMO-POS C-SNP)
|
Tier 4 - Non-Preferred |
— |
— |
✓
90 per 30 days
|
QL |