(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Diabetic Pen Needles and Syringes
PEN NEEDLES AND SYRINGES BY: ARKRAY HOME AIDE DIAGNOSTICS HTL-STREFA NOVO NORDISK OWEN MUMFORD PRODIGY DIABETES CARE SIMPLE DIAGNOSTICS TRIVIDIA (NIPRO DIAGNOSTICS) ULTIMED ALL OTHER DIABETIC PEN NEEDLES AND SYRINGES THAT ARE NOT LISTED AS PREFERRED
EMBECTA PEN NEEDLES EMBECTA SYRINGES
Diabetic Supply Kits
BIGFOOT UNITY PROGRAM KIT
DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors and Combinations
ALOGLIPTIN, BRYNOVIN, NESINA, SITAGLIPTIN, TRADJENTA, ZITUVIO ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, SITAGLIPTIN/METFORMIN, SITAGLIPTIN/METFORMIN ER, ZITUVIMET, ZITUVIMET XR
saxagliptin, sitagliptin phosphate
saxagliptin/metformin, sitagliptin phosphate/ metformin, JANUMET XR
ALOGLIPTIN/PIOGLITAZONE
pioglitazone plus saxagliptin or sitagliptin phosphate
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations
QTERN, STEGLUJAN
GLYXAMBI
Glucose-Elevating Drugs
GLUCAGON EMERGENCY KIT (by Fresenius), ZEGALOGUE
glucagon emergency kit (all manufacturers covered except Fresenius), BAQSIMI, GVOKE
Insulin (Basal) and Glucagon-Like Peptide-1 (GLP- 1) Agonist Combinations
XULTOPHY
SOLIQUA
Insulins
U-100: ADMELOG, APIDRA, FIASP, HUMALOG VIAL, INSULIN ASPART, KIRSTY, LYUMJEV, NOVOLOG, RELION NOVOLOG U-200: LYUMJEV Inhalation: AFREZZA U-100: BASAGLAR, BASAGLAR TEMPO, INSULIN DEGLUDEC, INSULIN GLARGINE-YFGN (by Civica), LEVEMIR, REZVOGLAR U-200: INSULIN DEGLUDEC INSULIN ASPART PROTAMINE, NOVOLOG MIX, RELION NOVOLOG MIX NOVOLIN, NOVOLIN MIX, RELION NOVOLIN, RELION NOVOLIN MIX BRENZAVVY, INVOKANA, STEGLATRO INVOKAMET, INVOKAMET XR, SEGLUROMET
U-100: HUMALOG (CARTRIDGE, KWIKPEN, JUNIOR KWIKPEN), INSULIN LISPRO, MERILOG U-200: HUMALOG KWIKPEN
U-100: INSULIN GLARGINE-YFGN (by Biocon), LANTUS, SEMGLEE (YFGN), TRESIBA U-200: TRESIBA U-300: INSULIN GLARGINE, TOUJEO HUMALOG MIX, INSULIN LISPRO PROTAMINE MIX
HUMULIN, HUMULIN MIX
Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors and Combinations
dapagliflozin, JARDIANCE
dapagliflozin/metformin ext-release, SYNJARDY, SYNJARDY XR
Sulfonylurea Agents
GLIMEPIRIDE 3MG TABLETS
glimepiride 1mg, 2mg or 4mg tablets glipizide 5mg and 10mg tablets
GLIPIZIDE 2.5MG AND 15MG TABLETS
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