North Carolina Alliance for Healthy Communities

Prescription Drug Coverage: Medicare Part D

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Prescription Drug Coverage & Medication Management

(Highlights drug coverage by plan, prior approval guidelines, critical forms and other helpful information for healthcare providers and consumers)

Plan Name	Company Name	Plan Type	Formulary List Site / pdf	Prior Authorization Criteria Site / pdf	Prior Athorization Form Site / pdf	Specific Forms by Drug
AARP MedicareComplete Choice	AARP MedicareComplete from SecureHorizons	MAPDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
AARP MedicareComplete Plus Plan 1	SecureHorizons by UnitedHealthcare	MAPDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
AARP MedicareRx Enhanced	UnitedHealthcare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
AARP MedicareRx Preferred	UnitedHealthcare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
AARP MedicareRx Saver	UnitedHealthcare	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Advantage Freedom Plan by RxAmerica	RxAmerica	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Advantage Star Plan by RxAmerica	RxAmerica	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Advantra	Coventry Health Care	MAPDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form
Advantra Freedom-Freedom 5	Advantra® Freedom	MAPDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Advantra Freedom-Freedom 5 Plus-GAP	Advantra® Freedom	MAPDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Advantra Freedom-Freedom 5 Plus-OTC	Advantra® Freedom	MAPDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
AdvantraRx Premier	Coventry AdvantraRx	PDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
AdvantraRx Premier Plus	Coventry AdvantraRx	PDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
AdvantraRx Value	Coventry AdvantraRx	PDP	Online Search and Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Aetna Medicare Rx Essentials	Aetna Medicare Rx Essentials	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
Aetna Medicare Rx Plus	Aetna Medicare Rx Plus	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
Aetna Medicare Rx Premier	Aetna Medicare Rx Premier	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
Blue Medicare PPO Enhanced Plus	PARTNERS National Health Plans, a BCBSNC company	MAPDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Blue Medicare Rx Enhanced	BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Blue Medicare Rx Standard	BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
BravoRx	Bravo Health	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
CIGNA Medicare Access Plus RX Plan Four	CIGNA Medicare Access	MAPDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
CIGNA Medicare Rx Plan One	CIGNA Medicare Rx	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
CIGNA Medicare Rx Plan Three	CIGNA Medicare Rx	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
CIGNA Medicare Rx Plan Two	CIGNA Medicare Rx	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
Community CCRx Basic	Universal American	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
Community CCRx Choice	Universal American	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
Community CCRx Gold	Universal American	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
EnvisionRxPlus Gold	EnvisionRx Plus	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
EnvisionRxPlus Silver	EnvisionRx Plus	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Evercare Plan DH	SecureHorizons by UnitedHealthcare	Special Needs	Online Search		Prior Authorization Form	No
Evercare Plan IH	SecureHorizons by UnitedHealthcare	Special Needs	Online Search		Prior Authorization Form	No
Evercare Plan MH	SecureHorizons by UnitedHealthcare	Special Needs	Online Search		Prior Authorization Form	No
Fidelis Secure Comfort	Fidelis SecureCare of North Carolina	Special Needs	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Fidelis Secure Comfort Plus	Fidelis SecureCare of North Carolina	Special Needs	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Fidelis Secure Independence	Fidelis SecureCare of North Carolina	Special Needs	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
First Health Part D-Premier	First Health Part D	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
First Health Part D-Secure	First Health Part D	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Fox Grand Plan	Fox Insurance Company	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Fox Value Plan	Fox Insurance Company	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	Yes
Health Net Orange Option 1	Health Net	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Health Net Orange Option 2	Health Net	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
HealthSpring Prescription Drug Plan -Reg 8	HealthSpring Prescription Drug Plan	PDP	Online Search Printable	Prior Authorization Criteria	Prior Authorization Form	No
Humana Gold Choice PFFS H1804-007	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
Humana Gold Choice PFFS H1804-016	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
Humana Gold Choice PFFS H1804-216	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
Humana Gold Choice PFFS H1804-217	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
Humana Gold Choice PFFS H1804-278	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
Humana Gold Choice PFFS H1804-279	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
Humana PDP Complete S5884-036	Humana Insurance Company	PDP	Printable		Prior Authorization Form	yes
Humana PDP Enhanced S5884-007	Humana Insurance Company	PDP	Printable		Prior Authorization Form	yes
Humana PDP Standard S5884-066	Humana Insurance Company	PDP	Printable		Prior Authorization Form	yes
HumanaChoicePPO PPO H3405-001	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
HumanaChoicePPO PPO H3405-002	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
HumanaChoicePPO PPO R5826-003	Humana Insurance Company	MAPDP	Online Search		Prior Authorization Form	Yes
HumanaChoicePPO PPO SNP-OA R5826-049	Humana Insurance Company	Special Needs	Online Search		Prior Authorization Form	Yes
Medco Medicare Prescription Plan - Access	Medco Medicare Prescription Plan	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Medco Medicare Prescription Plan - Choice	Medco Medicare Prescription Plan	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Medco Medicare Prescription Plan - Value	Medco Medicare Prescription Plan	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
MedicareRx Rewards Standard	UniCare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
MedicareRx Rewards Value	UniCare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
Patriot Plus	AMERICA'S 1ST CHOICE INSURANCE COMPANY OF NC, INC.	MAPDP	Printable	Prior Authorization Criteria
PrescribaRx Bronze	Pennsylvania Life Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
PrescribaRx Gold	Pennsylvania Life Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
PrescribaRx Platinum	Pennsylvania Life Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
Presidential Plus	AMERICA'S 1ST CHOICE INSURANCE COMPANY OF NC, INC.	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form
Presidential Plus Plan	AMERICA'S 1ST CHOICE INSURANCE COMPANY OF NC, INC.	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form
SecureHorizons MedicareDirect Rx Plan 54	SecureHorizons MedicareDirect	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
SecureHorizons MedicareDirect Rx Plan 55	SecureHorizons MedicareDirect	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
SecureHorizons MedicareDirect Rx Plan 56	SecureHorizons MedicareDirect	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
SecurityChoice Essential Plus	Unicare Life & Health Ins. Company	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
SecurityChoice Plus	Unicare Life & Health Ins. Company	MAPDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
Caremark Complete	SilverScript Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
Caremark Plus	SilverScript Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
SilverScript Value	SilverScript Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	Yes
Southeast Community Care - Dual Plus	Southeast Community Care	Special Needs	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Southeast Community Care - Plus	Southeast Community Care	MAPDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Sterling Option I	Sterling Life Insurance Company	MAPDP		Prior Authorization Criteria	Prior Authorization Form	No
Sterling Option II	Sterling Life Insurance Company	MAPDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Sterling Option IV	Sterling Life Insurance Company	MAPDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Sterling Rx	Sterling Life Insurance Company	PDP	Printable	Prior Authorization Criteria	Prior Authorization Form	No
Today's Options Access powered by CCRx	Universal American	MAPDP	Online Search Printable		Prior Authorization Form	Yes
Today's Options Value powered by CCRx	Universal American	MAPDP	Online Search		Prior Authorization Form	Yes
Today's Options Value powered by CCRx	Universal American	MAPDP	Online Search Printable		Prior Authorization Form	Yes
UA Medicare Part D Prescription Drug Cov	United American Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
UA Medicare Part D Rx Covg - Silver Plan	United American Insurance Company	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
UnitedHealth Rx Basic	UnitedHealthcare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
WellCare Classic	WellCare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No
WellCare Signature	WellCare	PDP	Online Search	Prior Authorization Criteria	Prior Authorization Form	No