Drug Name Tier Notes *INSULIN-INCRETIN MIMETIC COMBINATIONS*** SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 ST; QL XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 ST; QL *MEGLITINIDE ANALOGUES*** nateglinide oral tablet 2 QL repaglinide oral tablet 2 QL *PROGESTERONE RECEPTOR ANTAGONISTS*** mifepristone oral tablet 300 mg 4 PA; LD; QL *SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB*** TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** GLYXAMBI ORAL TABLET 2 ST; QL *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** dapagliflozin propanediol oral tablet 2 ST; QL FARXIGA ORAL TABLET 2 ST; QL JARDIANCE ORAL TABLET 2 ST; QL *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** dapagliflozin pro-metformin er oral tablet extended release 24 hour 2 ST; QL SYNJARDY ORAL TABLET 2 ST; QL Drug Name Tier Notes SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL *SULFONYLUREA- BIGUANIDE COMBINATIONS*** glipizide-metformin hcl oral tablet 1 or 1b* QL glyburide-metformin oral tablet 1 or 1b* QL *SULFONYLUREAS*** glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 or 1b* QL glipizide er oral tablet extended release 24 hour 1 or 1a* QL glipizide oral tablet 1 or 1a* QL glyburide micronized oral tablet 1 or 1b* QL glyburide oral tablet 1 or 1b* QL *SULFONYLUREA- THIAZOLIDINEDIONE COMBINATIONS*** pioglitazone hcl-glimepiride oral tablet 1 or 1b* ST; QL *THIAZOLIDINEDIONE- BIGUANIDE COMBINATIONS*** pioglitazone hcl-metformin hcl oral tablet 1 or 1b* ST; QL *THIAZOLIDINEDIONES *** pioglitazone hcl oral tablet 1 or 1b* ST; QL *ANTIDIARRHEAL/PRO BIOTIC AGENTS* *ANTIPERISTALTIC AGENTS*** diphenoxylate-atropine oral liquid 1 or 1b* diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 or 1b* loperamide hcl oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 24