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
Antidepressant Agents

Must try 2 of the following:

  • bupropion
  • citalopram
  • desvenlafaxine ER (generic)
  • duloxetine
  • escitalopram
  • fluoxetine
  • fluvoxamine
  • paroxetine
  • sertraline
  • vilazodone
  • venlafaxine
  • Desvenlafaxine ER (brand)
  • Fetzima
  • fluvoxamine ER
  • fluoxetine 90mg DR
  • Trintellix
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
Insulin - Long Acting
  • Lantus
  • Toujeo
  • Tresiba
Insulin - Pre-Mixed
  • Novolog Mix
  • Humalog Mix
Insulin - Short Acting
  • Novolog
  • Humalog
Pain
  • buprenorphine patch
  • hydromorphone ER
  • methadone
  • morphine ER
  • oxycodone ER
  • Nucynta ER
  • Tapentadol ER
  • Xtampza ER

Reviewed by LJS 4/8/26