Click on the Drug Class to see the Criteria In Use by Medical Mutual for coverage approval

Drug Class  Drugs in Class 
 Acne - Other Topical Products  Branded Topical Prescription Acne Products
 Acne - Topical Cleansers  Branded Prescription Acne Cleansers
 Acne - Topical Kits  Branded Prescription Acne Kits
 Actinic Keratosis  Aldara 5% cream, Carac 0.5% cream, Efudex 5% cream, Fluorouracil 0.5% cream, Fluorouracil 2% solution, Fluorouracil 5% cream, Fluorouracil 5% solution, Imiquimod 5% cream, Picato 0.015% gel, Picato 0.05% gel, Zyclara 2.5% cream, Zyclara 3.75% cream
 Angiotensin II Receptor Antagonists  Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Exforge HCT, Hyzaar, Micardis, Micardis HCT, Prexxartan, Teveten, Teveten HCT, Tribenzor, Twynsta
Antidepressants – Bupropion LA Antidepressant Therapy  Bupropion LA Products
 Antiepileptics  Briviact, Elepsia XR, Keppra, Keppra XR and Spritam
 Antifungal - topical  Ciclodan 8% Kit, CNL 8 Nail Kit, Jublia, Kerydin, Pedipirox-4 Nail Kit, Penlac
 Antipsychotic Agents  Caplyta, Rexulti
 Atopic Dermatitis  Elidel, Eucrisa, generic tacrolimus 0.03% or 0.1% ointment, Protopic
 Attention Deficit Hyperactivity Disorder  Adderall XR, Aptensio XR, Concerta, Daytrana, Dexedrine Spansules, Dyanavel XR, Focalin XR, Metadate CD, QuiliChew ER and IR, Ritalin LA and SR, Vyvanse, Adzenys ER suspension, Adzenys XR-ODT, Cotempla XR-ODT, Methylphenidate 72 mg ER (brand), Mydayis, Qullivant XR
 Avodart Avodart, Jalyn, Proscar
 Beta-Blocker  Branded Beta-blockers and Beta-blocker Combinations
 Beta2 Agonists (short-acting) Inhalers  Proventil HFA, Xopenex HFA
 Bile Acid Sequestrants  Cholestyramine, Colesevelam, Colestid, Colestipol, Prevalite, Questran, Welchol
 Bisphosphonates  Actonel, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D
 Buprenorphine  Belbuca, Butrans, Subutex
 Calcium Channel Blockers  Katerzia, Norliqva, Norvasc, Conjupri
 Contraceptives (Oral and Patch)  Branded Contraceptives
 Cyanocobalamin  Nascobal
 Cyclooxygenase-2 (COX-2) Inhibitor  Celebrex, Celecoxib
 Desmopressin  Desmopressin, Nocdurna
 Diabetes - Glucagon-Like Peptide-1 (GLP-1) Agonists  Adlyxin, Victoza
 Diabetic Test Strips  All products targeted except listed preferred. For members using the National Preferred/National Preferred Plus Formulary: Lifescan (e.g., OneTouch Ultra, OneTouch Verio) are PREFERRED, For members using the Basic/Basic Plus Formulary: Abbott (e.g., Freestyle, Freestyle Lite, Freestyle InsuLinx, Freestyle Neo), Lifescan (e.g., OneTouch Ultra, OneTouch Verio), other Abbott (Optium EZ, Optium, Precision PCX, Precision PCX Plus, Precision Point of Care, Precision Q-I-D, Precision Xtra, Ultima) are PREFERRED
 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors  Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni (alogliptin and pioglitazone)
 Epinephrine auto-injectors  epinephrine auto-injector pen (lineage), Epipen, Epipen Jr.
 Erectile Dysfunction  Levitra, Staxyn, Stendra, Viagra
 Expendable  Alcortin A, Alkindi Sprinkle, Allzital tablet, Amrix and generic, Android, Astagraf XL, Bupap tablet, butalbital 50 mg, acetaminophen 300 mg capsule, Carospir, Consensi, DexPak 6 day/10 day/13 day and generics, Durlaza, Dxevo dose pack, Envarsus XR, Epaned, Esgic capsule, Fexmid, Fioricet capsule, Fiorinal capsule, Flowtuss, Hemady, HiDex 6 day, Hycofenix, LoCort 7 day/11 day, Lorzone, Novacort gel, Obredon, Pliaglis and lidocaine 7% and tetracaine 7% cream (brand), Procysbi, Qbrelis, Rayos, Sitavig, Synera, Taperdex, Testred, Tussicaps, Tuzistra XR, Vanatol LQ, Vanatol S, Vituz, Xatmep, Yosprala and authorized generic, Zcort, zileuton extended-release tablets, Zodex 6 day/12 day, Zonacort 7 day/11 day, Zyflo
 Fenofibrate  Antara, fenofibrate 30mg, fenofibrate 40mg, fenofibrate 50mg, fenofibrate 90mg, fenofibrate 120mg, fenofibrate 150mg, Fenoglide, Fibricor, Lipofen, Tricor, Triglide and Trilipix
 Gabapentin  Gralise, Horizant, Lyrica, Neurontin, pregabalin
 Glaucoma Ophthalmic Alpha Adrenergic Agonist  Alphagan P 0.1%, Alphagan P 0.15%, Iopidine 0.5% and 1%
 Glaucoma Ophthalmic Beta-Adrenergic Blocker  Istalol, Betagan, Timoptic, Timoptic XE, Timoptic Ocudose
 Glaucoma Ophthalmic Carbonic Anhydrase Inhibitor  Trusopt
Glaucoma Ophthalmic Combination Product  Combigan, Cosopt
 Gout  Allopurinol, Duzallo, Probenecid, Probenecid/Colchicine, Uloric, Zurampic
 HMG-CoA Reductase Inhibitors  Altoprev, Caduet, Crestor, Livalo, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor
 Hormone Replacement Therapy Combo Patches  ClimaraPro
 Hydroxyurea  Siklos
 Hypnotics  Ambien, Ambien CR, Belsomra, Dayvigo, Edular, Intermezzo, Lunesta, Quviviq, Rozerem, Silenor, Sonata, Zolpimist
 Infertility - Follitropins  Bravelle, Follistim AQ, Gonal-F and Gonal-F RFF
 Infertility - Gonadotropin Releasing Hormone (GnRH) Antagonists  Ganirelix
 Inhaled Corticosteroid/Long-Acting Beta Agonists (ICS/LABA)  Fluticasone/salmeterol inhalation powder (authorized generic to AirDuo RespiClick), AirDuo RespiClick, AirDuo Digihaler, budesonide/formoterol inhalation aerosol (authorized generic to Symbicort)
 Insulin (other)  Novolin 70/30, Novolin N, Novolin R
 Insulin (rapid-acting)  Admelog, Apidra, Apidra Solostar, Novolog, Novolog Mix 70/30, Fiasp, NovoLog PenFill, NovoLog Flexpen, Novolog 70/30 FlexPen
 Inflammatory Bowel   Asacol, Asacol HD, Azulfidine/Azulfidine Entab, Colazal, Delzicol, Dipentum, Giazo, Lialda, Mesalamine 800mg
 Inhaled Corticosteroids  Alvesco, ArmonAir Digihaler
 
 Intranasal Steroids  Beconase AQ, Dymista, Nasonex, Omnaris, Qnasl, Rhinocort , Ticalast, Veramyst, Zetonna
 Isotretinoin  Absorica
 Lacosamide  Vimpat tablet and oral solution
 Long Acting Beta-Agonists (LABAs) for COPD  Brovana
 Methotrexate  Otrexup, Rasuvo, RediTrex
 Metoclopramide  Gimoti, Metoclopramide HCl oral solution, Metoclopramide orally disintegrating tablet (ODT), Reglan
 Nonsteroidal Anti-inflammatory Drug (NSAID)  Branded NSAIDs and topical diclofenac gel
 Ophthalmic Antihistamines  Alrex, Bepreve, Lastacaft, Zerviate
 Ophthalmic NSAIDS  Acular, Acular LS, Acuvail, Bromsite, Ilevro, Nevanac, Prolensa
 Ophthalmic Prostaglandin  Xalatan, Xelpros, Vyzulta, Zioptan, Rhopressa and Rocklatan
 Ophthalmic Steroids  FFML Forte, FML Liquifilm, FML S.O.P, Maxidex, Pred Mild
 Opioids (long-acting oral) Arymo ER, Hysingla ER, Kadian, MS Contin, Nucynta ER, Oxycodone extended-release (branded products), OxyContin, Xtampza ER, Zohydro ER
 Otic Antibiotics  Cetraxal, Ciprodex, Otovel
 Overactive Bladder  Darifenacin ER, Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique, Myrbetriq, Oxybutynin, Oxybutynin ER, Oxytrol, Tolterodine, Tolterodine ER, Toviaz, Trospium, Trospium ER, Vesicare
 Pancreatic Enzymes  Pancreaze, Pertzye, Ultresa
 Proton Pump Inhibitors (PPI)  Esomeprazole, Lansoprazole, Omeprazole, Omeprazole/Sodium Bicarbonate, Pantoprazole, Rabeprazole, Zegerid
 SGLT-2 Inhibitors  Farxiga, Invokana, Invokamet, Jardiance, Xigduo XR, Synjardy, Segluromet, Steglatro
 SGLT-2/DPP-4 Inhibitor Combinations SGLT-2/DPP-4 Inhibitor Combinations
SNRI Antidepressants Therapy SNRI Products
 Selective Serotonin Reuptake Inhibitors Antidepressants Therapy  SSRI Products
 Tetracyclines (oral)  Acticlate, Adoxa, Alodox, Avidoxy, Dynacin, Minocin, Minocycline ER, Monodox, Morgidox, Oracea, Solodyn, Vibramycin, Doxycline IR-DR, Ximino
 Topical Antibiotics  Altabax, Bactroban (mupirocin cream), Centany, Centany AT, Xepi
 Topical Corticosteroids  Branded Topical Corticosteriods
 Topical Podofilox  Condylox Gel
 Topical Rosacea  Finacea, MetroCream, MetroGel, MetroLotion, Noritate Cream, Rosadan, Soolantra, Zilxi
 Topical Vitamin D Analogs  Calcipotriene, Calcipotriene-Betamethasone and dipropionate, Enstilar, Sorilux, Taclonex, Wynzora
 Topiramate   Qudexy XR, Topamax, Topax Sprinkle, Trokendi, and Topiramate ER
 Transdermal Estrogen  Elestrin, EstroGel, Evamist, Divigel
 Triptan & Ergot Migraine Agents  Alsuma, Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Maxalt MLT, Onzetra Xsail, Zecuity, Relpax, Sumavel, Treximet, Trudhesa, zolmitriptan nasal spray, Zembrace, Zomig, Zomig-ZMT
 Truvada ST  Truvada
 Xeloda  Xeloda
 Zetia, Vytorin and Roszet  Vytorin, Zetia, Roszet