Drug Name Tier Notes *CEPHALOSPORINS - 3RD GENERATION*** cefdinir oral capsule 1 or 1b* cefdinir oral suspension reconstituted 1 or 1b* cefixime oral capsule 2 cefixime oral suspension reconstituted 2 cefpodoxime proxetil oral suspension reconstituted 2 cefpodoxime proxetil oral tablet 2 ceftazidime injection solution reconstituted 1 gm, 6 gm 2 ceftazidime intravenous solution reconstituted 2 ceftriaxone sodium in dextrose intravenous solution 2 ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg 2 ceftriaxone sodium intravenous solution reconstituted 2 tazicef injection solution reconstituted 1 gm 2 tazicef intravenous solution reconstituted 2 *CEPHALOSPORINS - 4TH GENERATION*** cefepime hcl injection solution reconstituted 1 gm 2 cefepime hcl intravenous solution reconstituted 2 gm 2 *CONTRACEPTIVES* *BIPHASIC CONTRACEPTIVES - ORAL*** azurette oral tablet 1 or 1b* $0 desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5) 1 or 1b* $0 kariva oral tablet 1 or 1b* $0 LO LOESTRIN FE ORAL TABLET 2 pimtrea oral tablet 1 or 1b* $0 simliya oral tablet 1 or 1b* $0 viorele oral tablet 1 or 1b* $0 Drug Name Tier Notes volnea oral tablet 1 or 1b* $0 *COMBINATION CONTRACEPTIVES - ORAL*** afirmelle oral tablet 1 or 1a* $0 altavera oral tablet 1 or 1a* $0 alyacen 1/35 oral tablet 1 or 1a* $0 apri oral tablet 1 or 1a* $0 aubra eq oral tablet 1 or 1a* $0 aurovela 1.5/30 oral tablet 1 or 1a* $0 aurovela 1/20 oral tablet 1 or 1a* $0 aurovela 24 fe oral tablet 1 or 1a* $0 aurovela fe 1.5/30 oral tablet 1 or 1a* $0 aurovela fe 1/20 oral tablet 1 or 1a* $0 aviane oral tablet 1 or 1a* $0 ayuna oral tablet 1 or 1a* $0 balziva oral tablet 1 or 1a* $0 blisovi 24 fe oral tablet 1 or 1a* $0 blisovi fe 1.5/30 oral tablet 1 or 1a* $0 blisovi fe 1/20 oral tablet 1 or 1a* $0 briellyn oral tablet 1 or 1a* $0 charlotte 24 fe oral tablet chewable 1 or 1a* $0 chateal eq oral tablet 1 or 1a* $0 cryselle-28 oral tablet 1 or 1a* $0 cyred eq oral tablet 1 or 1a* $0 dasetta 1/35 (28) oral tablet 1 or 1a* $0 delyla oral tablet 1 or 1a* $0 drospiren-eth estrad- levomefol oral tablet 1 or 1b* $0 drospirenone-ethinyl estradiol oral tablet 1 or 1b* $0 elinest oral tablet 1 or 1a* $0 enskyce oral tablet 0.15-30 mg-mcg 1 or 1a* $0 estarylla oral tablet 1 or 1a* $0 ethynodiol diac-eth estradiol oral tablet 1 or 1a* $0 falmina oral tablet 1 or 1a* $0 FEIRZA 1.5/30 ORAL TABLET 1 or 1a* $0 FEIRZA 1/20 ORAL TABLET 1 or 1a* $0 FINZALA ORAL TABLET CHEWABLE 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 42