Drug Name Tier Notes AREXVY INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 PA; AL; $0; QL AUDENZ INTRAMUSCULAR EMULSION 2 $0 AUDENZ INTRAMUSCULAR PREFILLED SYRINGE 2 $0 COMIRNATY INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 DENGVAXIA SUBCUTANEOUS SUSPENSION RECONSTITUTED 2 ENGERIX-B INJECTION SUSPENSION 20 MCG/ML 2 $0 ENGERIX-B INJECTION SUSPENSION PREFILLED SYRINGE 2 $0 ERVEBO INTRAMUSCULAR SUSPENSION 2 FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUBLOK INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 $0; QL FLUCELVAX INTRAMUSCULAR SUSPENSION 2 $0; QL FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLULAVAL INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUMIST NASAL LIQUID 2 $0; QL Drug Name Tier Notes FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL FLUZONE INTRAMUSCULAR SUSPENSION 2 $0; QL FLUZONE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0; QL GARDASIL 9 INTRAMUSCULAR SUSPENSION 2 $0 GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML 2 $0 HAVRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 2 $0 IMOVAX RABIES INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 IPOL INJECTION INJECTABLE 2 $0 IXCHIQ INTRAMUSCULAR SOLUTION RECONSTITUTED 2 IXIARO INTRAMUSCULAR SUSPENSION 2 JYNNEOS SUBCUTANEOUS SUSPENSION 2 $0 MODERNA COVID-19 VAC 6M-11Y INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 89