Prescription drug list
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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.
No material clinical/coverage changes in this update (has_material_change=false).
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.
Formulary access rules and flags
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
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.
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.
| 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) |
Provider actions & operational requirements
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 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
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
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
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
Policy effective date / current publication
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.