Drug Name Tier Notes *THYROID AGENTS* *ANTITHYROID AGENTS*** methimazole oral tablet 1 or 1a* propylthiouracil oral tablet 1 or 1b* *THYROID HORMONES*** euthyrox oral tablet 1 or 1b* levo-t oral tablet 1 or 1b* levothyroxine sodium oral capsule 2 levothyroxine sodium oral tablet 1 or 1a* levoxyl oral tablet 1 or 1a* liothyronine sodium intravenous solution 1 or 1b* liothyronine sodium oral tablet 1 or 1b* unithroid oral tablet 1 or 1a* *TOXOIDS* *TOXOID COMBINATIONS*** ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- MCG/0.5 2 $0 BOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 2 $0 INFANRIX INTRAMUSCULAR SUSPENSION 2 $0 KINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 PEDIARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 $0 Drug Name Tier Notes QUADRACEL INTRAMUSCULAR SUSPENSION 2 $0 QUADRACEL INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU 2 $0 VAXELIS INTRAMUSCULAR SUSPENSION 2 VAXELIS INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 *ULCER DRUGS/ANTISPASMODI CS/ANTICHOLINERGIC S* *ANTICHOLINERGIC COMBINATIONS*** chlordiazepoxide-clidinium oral capsule 1 or 1b* *ANTISPASMODICS*** dicyclomine hcl intramuscular solution 2 dicyclomine hcl oral capsule 1 or 1a* dicyclomine hcl oral solution 10 mg/5ml 1 or 1a* dicyclomine hcl oral tablet 1 or 1a* *H-2 ANTAGONISTS*** cimetidine hcl oral solution 300 mg/5ml 1 or 1b* cimetidine oral tablet 300 mg, 400 mg, 800 mg 1 or 1b* famotidine (pf) intravenous solution 1 or 1b* famotidine intravenous solution 200 mg/20ml, 40 mg/4ml 1 or 1b* famotidine oral suspension reconstituted 1 or 1b* famotidine oral tablet 40 mg 1 or 1b* famotidine premixed intravenous solution 1 or 1b* nizatidine oral capsule 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 86