NOTE: Not all plans cover these drugs nor require preauthorization. Please refer to the member's Individual Policy (also known as Certificate of Coverage, Master Contract or Plan Document) for information regarding coverage determination.

**This list does not guarantee coverage and is subject to change.**

STEP ONE STEP TWO
Antidiabetic-GLP1 Combinations
  • metformin-containing products
  • Type 2 diabetes diagnosis required
  • Soliqua*
  • Xultophy*

*Type 2 diabetes diagnosis required
Antifungal Agents-topical
  • ciclodan/ciclopirox
  • clotrimazole
  • econazole
  • ketoconazole
  • miconazole
  • naftifine
  • nystatin
  • oxiconazole
  • Ecoza
  • Ertaczo
  • Jublia
  • Oxistat
Antipsychotic Agents
  • aripiprazole
  • clozapine
  • lurasidone
  • olanzapine
  • paliperidone
  • quetiapine
  • risperidone
  • ziprasidone
  • Rexulti
  • Vraylar
Biliary Cirrhosis Agents
  • ursodiol
  • Ocaliva
Gastrointestinal Agents
  • Linzess
  • Motegrity
  • Trulance
Glaucoma
  • bimatoprost
  • latanoprost
  • tafluprost
  • travoprost
  • Lumigan
Pain
  • buprenorphine patch
  • hydromorphone ER
  • methadone
  • morphine ER
  • oxycodone ER
  • Nucynta ER
  • Xtampza ER

Reviewed by LJS/BNN 12/31/24