insulin degludec/liraglutide

100 unit-3.6 mg/mL (3 mL) — Pen Injector

Also known as: XULTOPHY 100-3.6

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 20 hours, 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA