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Xultophy
Sentara Health System
Sentara Health System Coverage for Xultophy
All
7
Commercial
4
Health Exchange
1
Managed Medicaid
1
Medicare
1
Commercial
Commercial - HMO
No PA
Step Therapy
Quantity Limit
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Commercial - PPO
No PA
Step Therapy
Quantity Limit
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Commercial - Point of Service
No PA
Step Therapy
Quantity Limit
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Commercial - Employer
No PA
Step Therapy
Quantity Limit
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Health Exchange
Health Exchange - HMO - Health Insurance Exchange
No PA
Step Therapy
Quantity Limit
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Managed Medicaid
Managed Medicaid - HMO - Medicaid
PA Required
Step Therapy
No Quantity Limit
See Details
Medicare
Medicare - Medicare Advantage Part D
No PA
No Step Therapy
No Quantity Limit
See Details
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