Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Bydureon exenatide microspheres 2 mg suspension, extended rel recon   $$$ Byetta exenatide 10 mcg/0.04 mL Pen Injector   Not Applicable Byetta exenatide 5 mcg/0.02 mL Pen Injector   Not Applicable Cycloset bromocriptine 0.8 mg tablet   Not Applicable Invokana canagliflozin 100 mg tablet; 300 mg tablet   Not Applicable Symlin pramlintide 600 mcg/mL Solution   Not Applicable SymlinPen 120 pramlintide 2,700 mcg/2.7 mL Pen Injector   Not Applicable SymlinPen 60 pramlintide 1,500 mcg/1.5 mL Pen Injector   Not Applicable Victoza liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) Pen Injector   Not Applicable WelChol colesevelam 3.75 gram Powder in Packet     Not Applicable WelChol colesevelam 625 mg tablet     Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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