Drug Name Tier Notes *VACCINES* *BACTERIAL VACCINES*** ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 2 $0 BCG VACCINE INJECTION SOLUTION RECONSTITUTED 2 $0 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 BIOTHRAX INTRAMUSCULAR SUSPENSION 2 CAPVAXIVE INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 $0 HIBERIX INJECTION SOLUTION RECONSTITUTED 2 $0 MENQUADFI INTRAMUSCULAR SOLUTION 2 $0 MENVEO INTRAMUSCULAR SOLUTION 2 $0 MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 2 $0 PEDVAX HIB INTRAMUSCULAR SUSPENSION 2 $0 PENBRAYA INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 $0 PNEUMOVAX 23 INJECTION SOLUTION PREFILLED SYRINGE 2 $0 PREVNAR 20 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 Drug Name Tier Notes TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML 2 TYPHIM VI INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 VAXCHORA ORAL SUSPENSION RECONSTITUTED 2 VAXNEUVANCE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 VIVOTIF ORAL CAPSULE DELAYED RELEASE 2 *VIRAL VACCINE COMBINATIONS*** M-M-R II INJECTION SOLUTION RECONSTITUTED 2 $0 PRIORIX SUBCUTANEOUS SUSPENSION RECONSTITUTED 2 $0 PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED 2 $0 TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 *VIRAL VACCINES*** ABRYSVO INTRAMUSCULAR SOLUTION RECONSTITUTED 2 $0; QL ACAM2000 INJECTION SOLUTION RECONSTITUTED 2 $0 AFLURIA INTRAMUSCULAR SUSPENSION 2 $0; QL AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 88