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Xultophy
Prominence Health Plan
Prominence Health Plan Coverage for Xultophy
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4
Commercial
3
Medicare
1
Commercial
Commercial - HMO
PA Required
No Step Therapy
No Quantity Limit
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Commercial - Point of Service
PA Required
No Step Therapy
No Quantity Limit
See Details
Commercial - PPO
PA Required
No Step Therapy
No Quantity Limit
See Details
Medicare
Medicare - Medicare Advantage Part D
No PA
No Step Therapy
Quantity Limit
See Details
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