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Covered Prescribed Drugs

DrugCovered Drug InformationCoverage CriteriaEffective Date of CoverageEnd Date of Coverage
Extencilline
(benzathine
Benzylpenicillin)		Covered as a
prescribed drug when
there is a drug
shortage identified
by the FDA*		Approved for use in
place of Bicillin LA		5/10/2024N/A
Lentocilin S
(penicillin G
benzathine)		Covered as a
prescribed drug when
there is a drug
shortage identified
by the FDA*		Approved for use in
place of Bicillin LA		8/5/2024N/A
Teglutik (riluzole)Covered as a
prescribed drug when
there is a drug
shortage identified
by the FDA*		Approved for
treatment of
amyotrophic lateral
sclerosis (ALS)		5/10/2024N/A
Soybean Oil and
Cholesterol
Powder Compound		Covered as a
prescribed drug		Approved for use in
treating Smith-Lemli-Opitz syndrome		5/10/2024N/A
Choline
Supplements		Covered as a
prescribed drug		Approved for
members who are
pregnant, planning to
become pregnant, or
breastfeeding		10/1/2024N/A


*Note: Select prescribed drugs that are not covered outpatient drugs (including drugs authorized for import by the Food and Drug Administration) are covered when medically necessary during drug shortages identified by the Food and Drug Administration.