SelectHealth Prescription Drug List (formulary summary)

Formulary Coverage Summary

This is a partial extract (Part 3 of 4) of the SelectHealth prescription drug list (formulary) summarizing commonly prescribed drugs, their tier placement, and plan-level requirement flags. The formulary applies to the plan's pharmacy benefit and is effective 2026-01-01. Coverage stance for the excerpt is mixed (some items have restrictions such as PA, ST, QL, M, AGE).

Formulary summary — key facts

Formulary effective date2026-01-01

Document partpartial (Part 3 of 4)

Coverage stancemixed

Line items listed (excerpt)100+

Formulary Requirement Flags (Meaning & Operational Notes)

Defined terms used in this excerpt include: PA (Preauthorization required), M (Maintenance drug — may allow a 90‑day supply or other managed requirement), ST (Step Therapy required), QL (Quantity Limits apply), and AGE (Age limit applies). Numeric thresholds and specific age cutoffs are not provided in this part of the formulary excerpt.

Tiered Drug & Supply Listing (excerpt)

Selected Oral AntidiabeticsmixedCovered

Pioglitazone Tablet (Bd Eclipse Mis)	Pioglitazone - oral hypoglycemic (thiazolidinedione)
Repaglinide Tablet (Bd Hypo Need Mis)	Repaglinide - meglitinide class, short-acting insulin secretagogue
Saxa/Metfor Tablet (Bd Integra Mis)	Saxagliptin/metformin combination tablet
Saxagliptin Tablet (Bd Luer-Lok Mis)	Saxagliptin - DPP-4 inhibitor
Xigduo Xr Tablet (Bd Plastipak Mis)	Dapagliflozin/metformin extended-release tablet

Selected GLP-1 / Injectable AntidiabeticsmixedCovered

Soliqua Injectable (Bd Needle Mis)	Insulin glargine/lixisenatide combination injectable
Trulicity Injectable (Bd Needles Mis)	Dulaglutide - GLP-1 receptor agonist injectable

Syringes & Injection Supplies (commonly used sizes)mixedCovered

1/2mL Tb Syr Mis (Bd Safety Mis)	0.5 mL tuberculin syringe, safety
10mL Ll Syrg Mis (Bd Syr 50mL Mis)	10 mL luer-lock syringe
10mL Syringe Mis (Bd Tb 1mL Mis)	10 mL general-purpose syringe
12mL Syringe Mis (Biotel Care Tes)	12 mL syringe
140mL Syring Mis (Blood Glucos Tes)	140 mL syringe (large-volume)
1mL Allr Syr Mis (Blulink Tes)	1 mL allergy/insulin syringe
1mL Slip Tip Mis (Blunt Cannul Mis)	1 mL slip-tip syringe
1mL Syringe Mis (Bulb Irr Syr Mis)	1 mL syringe
20mL Syringe Mis (Carepoint Sy Mis)	20 mL syringe
3mL Syringe Mis (Carepoint Tu Mis)	3 mL syringe

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Lancets & Test Strips / Meters (selected entries)mixedCovered

Accu-Chek Tes (Contour Tes)	Accu-Chek test strips / meter compatible
Accutrend Tes (Contour Plus Tes)	Accutrend test system
Advance Tes (Cvs Advanced Tes)	Advance glucose test strips
Advocate Tes (Cvs Glucose Tes)	Advocate glucose test system
Agamatrix Tes (Cvs True Met Tes)	Agamatrix test strips / meter
Assure Tes (Deflux Needl Mis)	Assure test strips
Assure Prism Tes (Diathrive+ Mis)	Assure Prism strips
Assure Pro Tes (Dropsafe Mis)	Assure Pro system
Autocode Tes (Duo-Care Tes)	Autocode compatible test system
Easy Touch (Gluconavii Tes)	Easy Touch meter / strips

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Miscellaneous Diabetes-related Supplies & NeedlesmixedCovered

Admix Needle Mis (Cool Blood Tes)	Admix needles
Eclipse Ndl Mis (Hw Embrace Tes / Hypo Needle Mis)	Eclipse needles / hypodermic needles
Fill Needle Mis (Luer-Lok Mis)	Fill needles for syringes
Poly Hub Mis (Yale Needles Mis)	Poly hub needles
Slip Tip 1mL Mis (Misoprostol Tablet)	Slip-tip 1 mL syringe
Slip Tip 3mL Mis (Sucralfate)	Slip-tip 3 mL syringe
Piston Irrig Mis (Verisafe Mis)	Piston irrigation supplies
Pharm Syrng Mis (Unistrip1 Tes)	Pharmacy syringe supplies

Formulary - notable classes & miscellaneous included items (excerpt)mixed

GROWTH HORMONES (Depo-Testost Injectable)	Selected hormone and specialty injectables
HEPATOTROPICS / Rezdiffra Tablet (Amjevita Injectable)	Hepatotropic agents and related injectables
HORMONE RECEPTOR MODULATORS (Bimzelx Injectable)	Selected immunomodulators and biologics
INFLUENZA AGENTS / Oseltamivir	Seasonal influenza antivirals
LAXATIVES and related bowel agents	OTC and prescription laxatives
LOCAL ANESTHETICS - TOPICAL (Lidocaine / Prilocaine)	Topical anesthetic preparations
MENTAL HEALTH (selected psychotropics)	Antidepressants, antipsychotics, mood stabilizers (representative listing)
OPHTHALMICS and OTIC preparations	Selected eye and ear topical agents
ONCOLOGY/HEMATOLOGY agents	Selected oncology medications and supportive care agents
OSTEOPOROSIS (bisphosphonates, teriparatide, romosozumab)	Bone health therapies

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This section presents an excerpt of drugs, supplies, and devices with their tier placement and any requirement flags shown as: (PA) prior authorization, (ST) step therapy, (QL) quantity limit, (M) maintenance (e.g., 90‑day supply eligibility), and (AGE) age limits. Inclusion in this formulary excerpt does not guarantee a provider will prescribe the drug; coverage is subject to medical necessity, plan terms, and any required prior authorization, step therapy, quantity limits, or age restrictions.

Provider Actions & Billing Impact

Prior Authorization

Preauthorization for certain drugs

SelectHealth requires prior authorization for certain drugs flagged with (PA). Providers must call Pharmacy Services to obtain prior authorization before dispensing items marked (PA) to avoid member financial responsibility. Phone: 800-538-5038. Include documentation of medical necessity with the PA request as indicated on the formulary.

Prior Authorization

Prior authorization required for designated items

Prior authorization is required for designated items noted on the formulary. Examples include but are not limited to: Mounjaro, Trulicity; Assure test kits; FreeStyle Libre kits; and many diabetes-related supplies. Verify each drug or device for a (PA) flag and secure authorization prior to dispensing.

Mounjaro
Trulicity

Drugs, Devices & Supply Items (coded listing)

Diabetes injectables & related supplies (mixed product descriptors)mixed

Gvoke Hypo 1 Injectable	Drug Tier = 3; Requirements & Limits = .
Gvoke Hypo 1 Injectable (Bd 20Ml Syrg Mis)	Drug Tier = 4; Requirements & Limits = (M).
Gvoke Hypo 2 Injectable	Drug Tier = 3; Requirements & Limits = .
Gvoke Hypo 2 Injectable (Bd 50Ml Syrg Mis)	Drug Tier = 4; Requirements & Limits = (M).
Metformin Tablet	Drug Tier = 1; Requirements & Limits = (M).
Metformin Tablet (Bd 5Ml Syrg Mis)	Drug Tier = 4; Requirements & Limits = (M).
Mounjaro Injectable	Drug Tier = 3; Requirements & Limits = (PA)(QL)(M).
Mounjaro Injectable (Bd Blnt Fill Mis)	Drug Tier = 4; Requirements & Limits = (M).
Pioglitazone Tablet	Drug Tier = 1; Requirements & Limits = (QL)(M).
Repaglinide Tablet	Drug Tier = 1; Requirements & Limits = (M).

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Vaccines & immunizations (mixed product descriptors)mixed

Comirnaty 5- Injectable	Drug Tier = 3; Requirements & Limits = (QL).
Havrix Injectable	Drug Tier = 3; Requirements & Limits = .
Heplisav-B Injectable	Drug Tier = 3; Requirements & Limits = (QL).
Ipol Injectable	Drug Tier = 3; Requirements & Limits = (AGE).
Shingrix Injectable	Drug Tier = 3; Requirements & Limits = (QL)(AGE).
Prevnar 20 Injectable	Drug Tier = 2; Requirements & Limits = .
Moderna Injectable	Drug Tier = 3; Requirements & Limits = (QL).
Novavax Injectable	Drug Tier = 3; Requirements & Limits = (QL).
Pfizer 6M-4Y Injectable	Drug Tier = 3; Requirements & Limits = (QL).
Pneumovax 23 Injectable	Drug Tier = 3; Requirements & Limits = (AGE).

Many entries in this excerpt present product names and tier placements rather than standardized procedure or NDC codes. Where NDCs are not shown, product descriptors (e.g., syringe or test-supply descriptors) are provided alongside the drug or device name.

Background & How This List Is Maintained

Background: the formulary is reviewed monthly by a committee of physicians and pharmacists, and the list summarizes commonly prescribed drugs and requirement flags. Inclusion in the formulary does not guarantee a provider will prescribe the drug. This file is a partial extract of the full SelectHealth formulary.

FAQ — How can I see the complete formulary and drug costs? Log in to your member account and use the drug search tool to view the full formulary and pricing, or call Pharmacy Services at 800-538-5038.

Clinical Evidence & Limitations

This excerpt contains no trial-level clinical evidence summaries. No clinical-evidence summaries or trial data are present in this part of the formulary extract.

Revision History

2026-01-01Effective DateLatest

Formulary extract effective date (partial extract).