Drug Name Tier Notes *B-COMPLEX W/ FOLIC ACID*** b complex formula 1 (w/ fa) oral tablet 1 or 1b* $0 b-complex (folic acid) oral tablet 1 or 1b* $0 b-complex/electrolytes oral tablet 1 or 1b* $0 big 100 oral tablet 1 or 1b* $0 kobee oral tablet 1 or 1b* $0 *B-COMPLEX W/BIOTIN & FOLIC ACID*** b complex 100 tr oral tablet extended release 1 or 1b* $0 b-100 b-complex oral tablet 1 or 1b* $0 b-100 complex cr oral tablet extended release 1 or 1b* $0 b-100 tr oral tablet extended release 1 or 1b* $0 b-50 complex oral tablet 1 or 1b* $0 balance b-50 oral tablet 1 or 1b* $0 balanced b complex oral tablet 1 or 1b* $0 balanced b-100 oral tablet 1 or 1b* $0 balanced b-100 oral tablet extended release 1 or 1b* $0 balanced b-50/fa oral tablet 1 or 1b* $0 b-compleet-100 oral tablet 1 or 1b* $0 b-compleet-50 oral tablet 1 or 1b* $0 b-complex oral tablet 1 or 1b* $0 big 100 (biotin) oral tablet 1 or 1b* $0 complex b-100 oral tablet extended release 1 or 1b* $0 complex b-50 prolonged release oral tablet extended release 1 or 1b* $0 endur-b oral tablet extended release 1 or 1b* $0 eql b complex 50 oral tablet 1 or 1b* $0 eql b-100 complex oral tablet extended release 1 or 1b* $0 ft b-100 complex pr oral tablet extended release 1 or 1b* $0 gnp b-100 complex oral tablet extended release 1 or 1b* $0 gnp b-50 complex oral tablet extended release 1 or 1b* $0 Drug Name Tier Notes qc b50 prolonged release oral tablet extended release 1 or 1b* $0 quin b strong b-25 oral tablet 1 or 1b* $0 ra balanced b-100 cr oral tablet extended release 1 or 1b* $0 ra balanced b-100 oral tablet 1 or 1b* $0 ra balanced b-50 oral tablet 1 or 1b* $0 ra balanced b-50 tr oral tablet extended release 1 or 1b* $0 super b-complex oral tablet 1 or 1b* $0 super dec b-100 oral tablet 1 or 1b* $0 super quints b-50 oral tablet 1 or 1b* $0 yl balanced b-100 oral tablet 1 or 1b* $0 *PED MULTI VITAMINS W/FL & FE*** multi-vitamin/fluoride/iron oral solution 1 or 1b* *PED MV W/ FLUORIDE*** multivitamin w/fluoride oral tablet chewable 1 or 1b* $0 multi-vitamin/fluoride oral solution 1 or 1b* $0 *PED VITAMINS ACD W/ FLUORIDE*** tri-vite/fluoride oral solution 1 or 1b* $0 *PRENATAL MV & MIN W/FE-FA*** ATABEX EC ORAL TABLET DELAYED RELEASE 2 QL ATABEX OB ORAL TABLET 2 QL CLASSIC PRENATAL ORAL TABLET 2 $0; QL C-NATE DHA ORAL CAPSULE 2 QL COMPLETENATE ORAL TABLET CHEWABLE 2 QL CO-NATAL FA ORAL TABLET 2 QL CONCEPT DHA ORAL CAPSULE 2 QL CONCEPT OB ORAL CAPSULE 2 QL elite-ob oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 74