CurrentSelectHealthPolicy N/A

Prescription drug list

Part 1 of 3 of SelectHealth's prescription drug list (formulary) summarizing commonly prescribed drugs, tier assignments, and plan-level usage flags such as Preauthorization (PA), Maintenance (M), Step Therapy (ST), Quantity Limits (QL), and Age limits (AGE). This part contains formulary policy intro, member guidance, and a long list of drug classes and individual drugs with tier and requirement flags.

Policy Summary

PayerSelectHealth

PolicyPrescription drug list

Policy CodePolicy N/A

Change TypeFormulary (no material changes)

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain preauthorization for drugs flagged (PA); if not authorized, member may be responsible for full retail price.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update (has_material_change=false).

multipleDrug entries in part

PA, ST, QL, M, AGECommon requirement flags present

multipleEntries with PA requirement

multipleEntries with QL/ST/AGE flags

100+

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Drugs/entries listed in part 3

Coverage summary & formulary scope

This document is Part 1 of 3 of SelectHealth's prescription drug list (formulary). It is a summary 'drug list' describing commonly prescribed drugs covered by the SelectHealth plan, showing representative tier assignments and plan-level controls that affect coverage and member cost-sharing. The full, complete formulary and pricing details are available via the member portal drug search tool or by contacting Pharmacy Services.

Policy dates and status

PayerSelectHealth

PolicyPrescription drug list (part 1)

Effective Date2026-01-01

StatusCURRENT

ScopePart 1 of 3 summarizing commonly prescribed drugs, tier assignments, and plan-level usage flags: Preauthorization (PA), Maintenance (M), Step Therapy (ST), Quantity Limits (QL), and Age limits (AGE).

Formulary access rules and flags

Coverage and access to listed drugs are governed by plan-level flags; drugs listed may require one or more of the following conditions:

Access constraints (one or more may apply)
- Preauthorization (PA): Preauthorization required (PA): Certain drugs require preauthorization; without it, member pays full retail price
  Source defines PA and lists many examples across the formulary
- Maintenance (M): Maintenance drugs (M): Allowance for 90-day supply for maintenance medications
  Source notes M denotes maintenance/90-day supply
- Step Therapy (ST): Drug covered only after trial and failure or intolerance to alternative therapy

Formulary entries (sample) and requirement flags

This section lists representative formulary entries included in Part 1 and shows each entry's tier and any requirement flags (for example: PA, ST, QL, M, AGE). It includes many drug product lines plus mapped supply and device entries (e.g., diabetes testing supplies, syringes, pump/patch device mappings) that appear with tier and requirement flags in this part. The full, searchable formulary (complete drug list and plan details) is available in the member portal and via Pharmacy Services.

Formulary entries with requirement flagsmixed

Fluorouracil Cream	Drug Tier = 4; Requirements & Limits: (PA)(QL) noted at header
Gvoke Hypo 1 Injectable	Listed as Drug Name for Fluorouracil Cream in header context
Gvoke Hypo 2 Injectable	Drug Tier = 4; Requirements & Limits = .; also appears with Drug Name = Bd Safety Mis and Tier = 5 with (M)
Metformin Tablet	Drug Tier = 2; Requirements & Limits = (M); also appears with Drug Name = Bd Syr 50Ml Mis, Tier=5, (M)
Mounjaro Injectable	Drug Tier = 4; Requirements & Limits = (PA)(QL)(M); alternate Drug Name = Bd Tb 1Ml Mis (Tier 5, (M))
Nateglinide Tablet	Drug Tier = 2; Requirements & Limits = (M); alt Drug Name = Blunt Cannul Mis (Tier 5, (M))
Pioglitazone Tablet	Drug Tier = 2; Requirements & Limits = (QL)(M)
Repaglinide Tablet	Drug Tier = 2; Requirements & Limits = (M)
Saxa/Metfor Tablet	Drug Tier = 2; Requirements & Limits = (QL)(M)
Saxagliptin Tablet	Drug Tier = 2; Requirements & Limits = (QL)(M)

1–10 of 43

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Provider actions & operational requirements

Prior Authorization

Preauthorization requirement

Obtain preauthorization for drugs flagged (PA); if not authorized, member may be responsible for full retail price.

Preauthorization requirement
Prior authorization required for select high-tier drugs
Prior authorization flags present

Step Therapy

Step therapy enforcement

For medications with (ST), ensure required trials of alternative therapies (and documentation of failure or intolerance) are completed before coverage is approved. Several formulary entries are marked (ST); follow plan step-therapy protocols and provide documentation when requested.

Step therapy enforcement
Step therapy flags present

Background and scope notes

Context: This formulary 'drug list' summary describes commonly prescribed drugs covered by SelectHealth and explains the tier structure that generally influences member cost-sharing (lower tiers typically cost less). It also highlights plan-level coverage controls used across entries — Preauthorization (PA), Step Therapy (ST), Quantity Limits (QL), Maintenance (M), and Age limits (AGE) — which may affect access and claim approval. This file is Part 1 of 3 of the full formulary summary.

Revision history

2026-01-01EffectiveLatest

Policy effective date / current publication

Policy Summary

PayerSelectHealth

PolicyPrescription drug list

Policy CodePolicy N/A

Change TypeFormulary (no material changes)

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain preauthorization for drugs flagged (PA); if not authorized, member may be responsible for full retail price.

SourceLink

On This Page

Source defines ST as requiring trial and failure of alternatives

Quantity Limits (QL): Quantity limits apply to certain drugs; preauthorization required if exceeding plan limits

Source defines QL and that PA is required if exceed limits

Age limit (AGE): A minimum or maximum age requirement must be met for coverage

Source defines AGE flag and shows many entries with AGE

Noncovered exceptions and formulary updates: Noncovered drug exceptions: A Drug Coverage Exception Form can be submitted for non-covered drugs based on medical necessity; decisions are case-by-case Formulary updates: The formulary is reviewed monthly and drugs may be added or removed based on clinical efficacy, safety, and cost-effectiveness

Source describes exception process and monthly review

PA (Preauthorization): Coverage of certain drugs requires preauthorization prior to coverage; without it the member may be responsible for full retail cost.

M (Maintenance): Maintenance drugs may permit a 90-day supply under plan rules.

ST (Step Therapy): Step therapy requires trial and failure or intolerance of specified alternatives before coverage for the requested drug is provided.

QL (Quantity Limits): Plan-set quantity limits apply; medications that exceed limits may require prior authorization.

AGE (Age limit): Coverage for some drugs requires meeting minimum or maximum age requirements.

Denial Risk

Quantity limit enforcement & Maintenance supply

Drugs with (QL) are subject to plan quantity limits; claims exceeding those limits risk denial unless preauthorization is obtained. Also, for medications designated (M), a 90-day maintenance supply may be permitted per plan rules.

Quantity limit enforcement
Maintenance 90-day supply

Documentation Required

Drug coverage exception process; documentation & age limits

Submit a Drug Coverage Exception Form (available on the SelectHealth website) for noncovered drugs when requesting coverage based on medical necessity; requests are decided case-by-case. Many formulary entries include QL and M flags; document indication, quantity, and prescriber specialty as required. Several entries include (AGE) indicating age-specific coverage limits—ensure patient age is documented when submitting claims.

Drug coverage exception process
Quantity limits and medical specialty flags
Age limits