Drug Name Tier Notes *ERGOT COMBINATIONS*** ergotamine-caffeine oral tablet 1 or 1b* migergot rectal suppository 1 or 1b* *MIGRAINE PRODUCTS*** dihydroergotamine mesylate injection solution 1 or 1b* PA; QL *SELECTIVE SEROTONIN AGONISTS 5-HT(1)*** almotriptan malate oral tablet 1 or 1b* QL eletriptan hydrobromide oral tablet 1 or 1b* QL frovatriptan succinate oral tablet 1 or 1b* ST; QL naratriptan hcl oral tablet 1 or 1b* QL rizatriptan benzoate oral tablet 1 or 1b* QL rizatriptan benzoate oral tablet dispersible 1 or 1b* QL sumatriptan nasal solution 1 or 1b* QL sumatriptan succinate oral tablet 1 or 1b* QL sumatriptan succinate refill subcutaneous solution cartridge 2 QL sumatriptan succinate subcutaneous solution 6 mg/0.5ml 2 QL sumatriptan succinate subcutaneous solution auto- injector 4 mg/0.5ml, 6 mg/0.5ml 2 QL zolmitriptan nasal solution 1 or 1b* ST; QL zolmitriptan oral tablet 1 or 1b* QL zolmitriptan oral tablet dispersible 1 or 1b* QL *MINERALS & ELECTROLYTES* *BICARBONATES*** sodium acetate intravenous solution 4 meq/ml 1 or 1b* sodium bicarbonate intravenous solution 4.2 %, 7.5 % 2 Drug Name Tier Notes *ELECTROLYTES & DEXTROSE*** dextrose in lactated ringers intravenous solution 1 or 1b* dextrose-sodium chloride intravenous solution 10-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5-0.9 % 1 or 1b* kcl in dextrose-nacl intravenous solution 10-5- 0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/l- %-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-% 1 or 1b* potassium cl in dextrose 5% intravenous solution 10 meq/l, 20 meq/l 1 or 1b* *ELECTROLYTES PARENTERAL*** KCL (0.149%) IN NACL INTRAVENOUS SOLUTION 20-0.45 MEQ/L-% 1 or 1b* kcl (0.149%) in nacl intravenous solution 20-0.9 meq/l-% 1 or 1b* KCL (0.298%) IN NACL INTRAVENOUS SOLUTION 1 or 1b* lactated ringers intravenous solution 1 or 1b* multiple electro type 1 ph 5.5 intravenous solution 1 or 1b* multiple electro type 1 ph 7.4 intravenous solution 1 or 1b* ringers intravenous solution 1 or 1b* *FLUORIDE*** sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 or 1a* $0 sodium fluoride oral tablet 1 or 1a* $0 sodium fluoride oral tablet chewable 1 or 1a* $0 *MAGNESIUM*** MAGNESIUM SULFATE INJECTION SOLUTION 50 % 2 *MANGANESE*** manganese chloride intravenous solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 70