Drug Name Tier Notes errin oral tablet 1 or 1b* $0 heather oral tablet 1 or 1b* $0 incassia oral tablet 1 or 1b* $0 jencycla oral tablet 1 or 1b* $0 lyleq oral tablet 1 or 1b* $0 lyza oral tablet 1 or 1b* $0 MELEYA ORAL TABLET 1 or 1b* $0 nora-be oral tablet 1 or 1b* $0 norethindrone oral tablet 1 or 1b* $0 norlyroc oral tablet 1 or 1b* $0 OPILL ORAL TABLET 2 $0 sharobel oral tablet 1 or 1b* $0 *TRIPHASIC CONTRACEPTIVES - ORAL*** alyacen 7/7/7 oral tablet 1 or 1a* $0 aranelle oral tablet 1 or 1a* $0 dasetta 7/7/7 oral tablet 1 or 1a* $0 enpresse-28 oral tablet 1 or 1a* $0 leena oral tablet 1 or 1a* $0 levonest oral tablet 1 or 1a* $0 levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125- 30 mcg 1 or 1a* $0 norgestim-eth estrad triphasic oral tablet 1 or 1b* $0 nortrel 7/7/7 oral tablet 1 or 1a* $0 nylia 7/7/7 oral tablet 1 or 1a* $0 tilia fe oral tablet 1 or 1b* $0 tri-estarylla oral tablet 1 or 1b* $0 tri-legest fe oral tablet 1 or 1b* $0 tri-linyah oral tablet 1 or 1b* $0 tri-lo-estarylla oral tablet 1 or 1b* $0 tri-lo-marzia oral tablet 1 or 1b* $0 tri-lo-mili oral tablet 1 or 1b* $0 tri-lo-sprintec oral tablet 1 or 1b* $0 tri-mili oral tablet 1 or 1b* $0 tri-sprintec oral tablet 1 or 1b* $0 trivora (28) oral tablet 1 or 1a* $0 tri-vylibra lo oral tablet 1 or 1b* $0 tri-vylibra oral tablet 1 or 1b* $0 velivet oral tablet 1 or 1a* $0 XARAH FE ORAL TABLET 1 or 1b* $0 Drug Name Tier Notes *CORTICOSTEROIDS* *GLUCOCORTICOSTER OIDS*** budesonide er oral tablet extended release 24 hour 2 QL budesonide oral capsule delayed release particles 2 QL dexameth sod phos (pf) +rfid injection solution prefilled syringe 1 or 1b* DEXAMETHASONE INTENSOL ORAL CONCENTRATE 2 dexamethasone oral elixir 1 or 1a* dexamethasone oral solution 1 or 1a* dexamethasone oral tablet 1 or 1a* dexamethasone oral tablet therapy pack 1 or 1b* dexamethasone sod phos +rfid injection solution prefilled syringe 1 or 1b* dexamethasone sod phosphate pf injection solution 1 or 1b* DEXAMETHASONE SOD PHOSPHATE PF INJECTION SOLUTION PREFILLED SYRINGE 1 or 1b* dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml 1 or 1b* DEXAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION PREFILLED SYRINGE 1 or 1b* hidex 6-day oral tablet therapy pack 1 or 1b* hydrocortisone oral tablet 1 or 1b* hydrocortisone sod suc (pf) injection solution reconstituted 1 or 1b* methylprednisolone oral tablet 1 or 1a* methylprednisolone oral tablet therapy pack 1 or 1a* methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 45