Drug Name Tier Notes cvs nicotine mouth/throat lozenge 1 or 1b* $0 cvs nicotine polacrilex mouth/throat gum 1 or 1b* $0 cvs nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 cvs nicotine transdermal patch 24 hour 1 or 1b* $0 eq nicotine mouth/throat lozenge 1 or 1b* $0 eq nicotine polacrilex mouth/throat gum 1 or 1b* $0 eq nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 eq nicotine step 3 transdermal patch 24 hour 1 or 1b* $0 eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr 1 or 1b* $0 ft nicotine mini mouth/throat lozenge 1 or 1b* $0 ft nicotine mouth/throat gum 1 or 1b* $0 ft nicotine mouth/throat lozenge 1 or 1b* $0 ft nicotine transdermal patch 24 hour 1 or 1b* $0 gnp nicotine mini mouth/throat lozenge 1 or 1b* $0 gnp nicotine mouth/throat gum 1 or 1b* $0 gnp nicotine polacrilex mouth/throat gum 1 or 1b* $0 gnp nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 gnp nicotine transdermal patch 24 hour 1 or 1b* $0 goodsense nicotine mouth/throat gum 1 or 1b* $0 goodsense nicotine mouth/throat lozenge 1 or 1b* $0 habitrol transdermal patch 24 hour 1 or 1b* $0 kls quit2 mouth/throat gum 1 or 1b* $0 kls quit2 mouth/throat lozenge 1 or 1b* $0 kls quit4 mouth/throat gum 1 or 1b* $0 kls quit4 mouth/throat lozenge 1 or 1b* $0 Drug Name Tier Notes NICODERM CQ TRANSDERMAL PATCH 24 HOUR 2 $0 NICORETTE MINI MOUTH/THROAT LOZENGE 2 $0 NICORETTE MOUTH/THROAT GUM 2 $0 NICORETTE MOUTH/THROAT LOZENGE 2 $0 NICORETTE STARTER KIT MOUTH/THROAT GUM 2 $0 nicotine mini mouth/throat lozenge 1 or 1b* $0 nicotine polacrilex mini mouth/throat lozenge 1 or 1b* $0 nicotine polacrilex mouth/throat gum 1 or 1b* $0 nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 nicotine step 1 transdermal patch 24 hour 1 or 1b* $0 nicotine step 2 transdermal patch 24 hour 1 or 1b* $0 nicotine step 3 transdermal patch 24 hour 1 or 1b* $0 NICOTINE TRANSDERMAL KIT 2 $0 nicotine transdermal patch 24 hour 1 or 1b* $0 NICOTROL INHALATION INHALER 2 $0; QL NICOTROL NS NASAL SOLUTION 2 $0; QL qc nicotine transdermal system transdermal patch 24 hour 1 or 1b* $0 ra mini nicotine mouth/throat lozenge 1 or 1b* $0 ra nicotine gum mouth/throat gum 2 mg, 4 mg 1 or 1b* $0 ra nicotine mouth/throat gum 1 or 1b* $0 ra nicotine polacrilex mouth/throat lozenge 1 or 1b* $0 ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 84