Drug Name Tier Notes *VAGINAL PROGESTINS*** ENDOMETRIN VAGINAL INSERT 2 PA *VASOPRESSORS* *ANAPHYLAXIS THERAPY AGENTS*** epinephrine (anaphylaxis) injection solution 1 or 1b* epinephrine injection solution auto-injector 1 or 1b* QL *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** droxidopa oral capsule 4 PA; LD; QL; SP *VASOPRESSORS*** midodrine hcl oral tablet 2 *VITAMINS* *VITAMIN B-1*** thiamine hcl injection solution 1 or 1b* *VITAMIN D*** ergocalciferol oral capsule 1 or 1a* vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit 1 or 1a* *VITAMIN K*** phytonadione injection solution 1 mg/0.5ml, 10 mg/ml 1 or 1b* phytonadione oral tablet 2 vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 91