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Xultophy
Jefferson Health Plans (MCO)
Jefferson Health Plans (MCO) Coverage for Xultophy
All
4
Health Exchange
2
Managed Medicaid
1
Medicare
1
Health Exchange
Health Exchange - HMO - Health Insurance Exchange
No PA
Step Therapy
Quantity Limit
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Health Exchange - PPO - Health Insurance Exchange
No PA
Step Therapy
Quantity Limit
See Details
Managed Medicaid
Managed Medicaid - HMO - Medicaid
PA Required
Step Therapy
Quantity Limit
See Details
Medicare
Medicare - Medicare Advantage Part D
No PA
No Step Therapy
No Quantity Limit
See Details
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