Drug Name Tier Notes ULTRA THIN PEN NEEDLES 3 ST; QL ULTRACARE INSULIN SYRINGE 3 ST; QL ULTRACARE PEN NEEDLES 3 ST; QL ULTRA-THIN II INS SYR SHORT 3 ST; QL ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML 3 ST; QL ULTRA-THIN II MINI PEN NEEDLE 3 ST; QL ULTRA-THIN II PEN NEEDLE SHORT 3 ST; QL ULTRA-THIN II PEN NEEDLES 3 ST; QL UNIFINE OTC PEN NEEDLES 3 ST; QL UNIFINE PENTIPS 3 ST; QL UNIFINE PENTIPS PLUS 3 ST; QL UNIFINE PROTECT PEN NEEDLE 30G X 5 MM 3 QL UNIFINE PROTECT PEN NEEDLE 30G X 8 MM , 32G X 4 MM 3 ST; QL UNIFINE SAFECONTROL PEN NEEDLE 3 ST; QL UNIFINE ULTRA PEN NEEDLE 3 ST; QL VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML 3 ST; QL VANISHPOINT INSULIN SYRINGE 30G X 3/16" 0.5 ML, 30G X 3/16" 1 ML 3 QL VERIFINE INSULIN PEN NEEDLE 29G X 12MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM 3 ST; QL VERIFINE INSULIN PEN NEEDLE 31G X 5 MM 3 QL VERIFINE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML 3 ST; QL Drug Name Tier Notes VERIFINE INSULIN SYRINGE 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML 3 QL VERIFINE PLUS PEN NEEDLE 3 ST; QL WEGMANS UNIFINE PENTIPS PLUS 3 ST; QL ZEVRX INSULIN SYRINGE 3 ST; QL ZEVRX PEN NEEDLES 3 ST; QL *MIGRAINE PRODUCTS* *CALCITONIN GENE- RELATED PEPTIDE RECEPTOR ANTAG (CGRP)*** NURTEC ORAL TABLET DISPERSIBLE 2 PA; QL QULIPTA ORAL TABLET 2 PA; QL UBRELVY ORAL TABLET 2 ST; QL *CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES*** AIMOVIG SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL EMGALITY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 69