Drug Name Tier Notes EQL PRENATAL FORMULA ORAL TABLET 2 $0; QL FOLIVANE-OB ORAL CAPSULE 85-1 MG 2 QL GNP PRENATAL ORAL TABLET 2 $0; QL inatal gt oral tablet 1 or 1b* QL M-NATAL PLUS ORAL TABLET 1 or 1b* QL NIVA-PLUS ORAL TABLET 2 QL ONE VITE WOMENS PLUS ORAL TABLET 2 QL pnv 27-ca/fe/fa oral tablet 2 ST; QL pnv prenatal plus multivit+dha oral 2 QL pnv-select oral tablet 1 or 1b* ST; QL PRENATAL (W/IRON & FA) ORAL TABLET 2 ST; $0; QL PRENATAL 19 ORAL TABLET 29-1 MG 2 QL prenatal 19 oral tablet chewable 1 or 1a* QL PRENATAL 19 ORAL TABLET CHEWABLE 29- 1 MG 2 QL PRENATAL COMPLETE ORAL TABLET 2 ST; $0; QL PRENATAL ORAL TABLET 27-1 MG 2 QL PRENATAL PLUS ORAL TABLET 2 QL PRENATAL PLUS VITAMIN/MINERAL ORAL TABLET 2 QL PRENATAL VITAMIN AND MINERAL ORAL TABLET 2 $0; QL PRENATAL VITAMINS ORAL TABLET 28-0.8 MG 2 $0; QL PRENATAL-U ORAL CAPSULE 2 QL PROVIDA OB ORAL CAPSULE 2 QL QC PRENATAL ORAL TABLET 2 $0; QL Drug Name Tier Notes RA PRENATAL ORAL TABLET 2 $0; QL SELECT-OB ORAL TABLET CHEWABLE 29- 1 MG 2 QL SE-NATAL 19 ORAL TABLET 2 QL SE-NATAL 19 ORAL TABLET CHEWABLE 2 QL TARON-C DHA ORAL CAPSULE 35-1 MG 2 QL THRIVITE RX ORAL TABLET 2 ST; QL TRINATAL RX 1 ORAL TABLET 2 QL trinate oral tablet 1 or 1a* QL VITAFOL GUMMIES ORAL TABLET CHEWABLE 2 QL WESTAB PLUS ORAL TABLET 2 QL *PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL*** COMPLETE NATAL DHA ORAL 29-1-200 & 200 MG 2 QL wesnatal dha complete oral 2 QL *PRENATAL MV & MIN W/FE-FA-DHA*** ENFAMIL EXPECTA ORAL 2 $0; QL pnv-dha oral capsule 1 or 1b* QL prena 1 true oral 2 PRENATAL MULTIVITAMIN + DHA ORAL 2 $0; QL *VITAMINS W/ LIPOTROPICS*** b complex formula 1 (lipotrop) oral tablet 1 or 1b* $0 balance b-100 oral tablet 1 or 1b* $0 balanced b-50 complex oral tablet 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 75