Drug Name Tier Notes *BIGUANIDES*** metformin hcl er oral tablet extended release 24 hour 1 or 1b* QL metformin hcl oral solution 3 PA; QL metformin hcl oral tablet 1000 mg, 500 mg 1 or 1b* QL metformin hcl oral tablet 850 mg 1 or 1b* $0; QL *DIABETIC OTHER*** BAQSIMI ONE PACK NASAL POWDER 3 QL BAQSIMI TWO PACK NASAL POWDER 3 QL diazoxide oral suspension 2 GLUCAGON EMERGENCY INJECTION KIT 1 or 1b* QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED 3 QL GVOKE HYPOPEN 1- PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 QL GVOKE HYPOPEN 2- PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 QL GVOKE KIT SUBCUTANEOUS SOLUTION 3 QL GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 MG/0.2ML 3 QL ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 QL ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** alogliptin benzoate oral tablet 1 or 1b* ST; QL JANUVIA ORAL TABLET 2 ST; QL Drug Name Tier Notes *DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS*** alogliptin-metformin hcl oral tablet 1 or 1b* ST; QL JANUMET ORAL TABLET 2 ST; QL JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 ST; QL *DPP-4 INHIBITOR- THIAZOLIDINEDIONE COMBINATIONS*** alogliptin-pioglitazone oral tablet 12.5-30 mg, 25-15 mg, 25-30 mg, 25-45 mg 1 or 1b* ST; QL *HUMAN INSULIN*** HUMALOG INJECTION SOLUTION 2 QL HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML 2 QL HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION 2 QL HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 2 QL HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 22