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
Albuterol Inhalers
  • albuterol HFA
  • levalbuterol HFA
  • ProAir Digihaler
  • ProAir HFA
  • ProAir Respiclick
  • Ventolin HFA
  • Proventil HFA
Antidiabetic-GLP1
  • metformin-containing products
  • Type 2 diabetes diagnosis required
  • Mounjaro*
  • Ozempic*
  • Rybelsus*
  • Trulicity*
  • Victoza*

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

*Type 2 diabetes diagnosis required
Antidepressants-SNRI
  • bupropion
  • citalopram
  • desvenlafaxine ER (generic)
  • duloxetine
  • escitalopram
  • fluoxetine
  • fluvoxamine
  • paroxetine
  • sertraline
  • venlafaxine
  • Desvenlafaxine ER (brand)
Antifungal Agents-topical
  • ciclodan/ciclopirox
  • clotrimazole
  • econazole
  • ketoconazole
  • miconazole
  • naftifine
  • nystatin
  • oxiconazole
  • Ecoza
  • Ertaczo
  • Jublia
  • Oxistat
Biliary Cirrhosis Agents
  • ursodiol
  • Ocaliva
Glaucoma
  • bimatoprost
  • latanoprost
  • tafluprost
  • travoprost
  • Lumigan (brand)
Pain
  • buprenorphine patch
  • hydromorphone ER
  • methadone
  • morphine ER
  • oxycodone ER
  • Nucynta ER
  • Xtampza ER

Reviewed by LJS 6/14/24

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