Continuous Glucose Monitors including Dexcom and Freestyle Libre Continuous Glucose Monitorsĭiabetic Durable Medical Equipment coverage under the medical certificate of coverageĭiabetic equipment for diabetes includes but is not limited to:.Public Options Plans – benefits for diabetic supplies Benefits for diabetic supplies provided under the outpatient prescription drug benefitĬertain diabetic supplies will be covered at zero-dollar cost share not subject to any deductible: Essential Tier 4 Prescription drug List DMHC Version ( cycle).Essential Tier 4 Prescription drug List DMHC Version ().Access Tier 4 HMO and PPO Prescription Drug List DMHC Version ( cycle).Access Tier 4 HMO and PPO Prescription Drug List DMHC Version ().Access Tier 4 PPO Prescription Drug List CDI Version ( cycle).Access Tier 4 PPO Prescription Drug List CDI Version ().Access Tier 3 HMO and PPO Prescription Drug List DMHC Version ( cycle).Access Tier 3 HMO and PPO Prescription Drug List DMHC Version ().Access Tier 3 PPO Prescription Drug List CDI Version ( cycle).Access Tier 3 PPO Prescription Drug List CDI Version ().Large Group Tier 4 HMO and PPO Prescription Drug List DMHC Version ( cycle).Large Group Tier 4 HMO and PPO Prescription Drug List DMHC Version ().Large Group Tier 4 PPO Prescription Drug List CDI Version ( cycle).Large Group Tier 4 PPO Prescription Drug List CDI Version ().Large Group Tier 3 HMO and PPO Prescription Drug List DMHC Version ( cycle).Large Group Tier 3 HMO and PPO Prescription Drug List DMHC Version ().Large Group Tier 3 PPO Prescription Drug List CDI Version ( cycle).Large Group Tier 3 PPO Prescription Drug List CDI Version ().Standard Tier 4 HMO and PPO Prescription Drug List DMHC Version ( cycle).Standard Tier 4 HMO and PPO Prescription Drug List DMHC Version ().Standard Tier 4 PPO Prescription Drug List CDI Version ( cycle).Standard Tier 4 PPO Prescription Drug List CDI Version ().Search for your Tier 4 drugs on the Formulary Viewer. Search for your Tier 3 drugs on the Formulary Viewer. If you need an exclusion exception, view our process as described in Your Right to Request an Exclusion Exception. The following Prescription Drug Lists for California may be refreshed on a monthly basis. Essential Tier 4 Prescription Drug List for UnitedHealthcare, All Savers, Golden Rule, Neighborhood Health Plan and River Valley medical plans ().Traditional Tier 4 Prescription Drug List for UnitedHealthcare and Student Resources medical plans ().Traditional Tier 3 Prescription Drug List for UnitedHealthcare, River Valley, Oxford and Student Resources medical plans ().Access Tier 4 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans ().Access Tier 3 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans ().Advantage Tier 4 Prescription Drug List for UnitedHealthcare, Golden Rule, UnitedHealthOne, Oxford, All Savers, Neighborhood Health Plan and River Valley medical plans ().Advantage Tier 3 Prescription Drug List for UnitedHealthcare, Neighborhood Health Plan, River Valley, All Savers, and Oxford medical plans ().Specialty medications not eligible for coupons ().These PDLs are for general plans that include a pharmacy benefit.

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