Drug Class
Excluded Medications
Preferred Alternatives
DERMATOLOGICAL Miscellaneous Topical Dermatological Agents (continued)
TRI-LUMA
fluocinolone, hydroquinone, tretinoin
VEREGEN
imiquimod 5% cream, podofilox gel or solution
DIABETES Biguanidine Agents
METFORMIN 625MG TABLETS
metformin 500mg, 850mg or 1,000mg tablets
ABBOTT FREESTYLE KITS/METERS (FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE) ABBOTT FREESTYLE TEST STRIPS (FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE PRECISION NEO) ABBOTT PRECISION XTRA METERS, TEST STRIPS TRIVIDIA METERS (TRUE METRIX AIR, TRUE METRIX, TRUE METRIX GO) TRIVIDIA TEST STRIPS (TRUE METRIX, TRUETRACK)
ASCENSIA (CONTOUR) ELI LILLY (TEMPO) LIFESCAN (ONETOUCH SOLUTIONS STARTER, ULTRA, ULTRA2, VERIO, VERIO FLEX) ROCHE (ACCU-CHEK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED
Blood Glucose Meters & Test Strips
DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR
Continuous Glucose Monitoring Systems
EVERSENSE 365: SENSOR, TRANSMITTER
PEN NEEDLES & 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 & SYRINGES THAT ARE NOT LISTED AS PREFERRED
EMBECTA PEN NEEDLES EMBECTA SYRINGES
Diabetic Pen Needles & Syringes
DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR
Diabetic Supply Kits
BIGFOOT UNITY PROGRAM KIT
ALOGLIPTIN, NESINA, SITAGLIPTIN, TRADJENTA, ZITUVIO ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, SITAGLIPTIN/METFORMIN, SITAGLIPTIN/METFORMIN ER, ZITUVIMET, ZITUVIMET XR
saxagliptin, JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations
saxagliptin/metformin, JANUMET, JANUMET XR
ALOGLIPTIN/PIOGLITAZONE
pioglitazone plus saxagliptin or JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations
QTERN, STEGLUJAN
GLYXAMBI
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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