Drug Name Tier Notes MRESVIA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 AL; $0; QL novavax covid-19 vaccine intramuscular suspension prefilled syringe 2 $0 PFIZER COVID-19 VAC- TRIS 5-11Y INTRAMUSCULAR SUSPENSION 10 MCG/0.3ML 2 $0 pfizer covid-19 vac-tris 6m- 4y intramuscular suspension 3 mcg/0.3ml 2 $0 RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED 2 RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML 2 $0 RECOMBIVAX HB INJECTION SUSPENSION PREFILLED SYRINGE 2 $0 ROTARIX ORAL SUSPENSION 2 $0 ROTATEQ ORAL SOLUTION 2 $0 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML 2 $0 SPIKEVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 $0 STAMARIL INJECTION SUSPENSION RECONSTITUTED 2 TICOVAC INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML 2 $0 Drug Name Tier Notes VARIVAX INJECTION SUSPENSION RECONSTITUTED 2 $0 VIMKUNYA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2 YF-VAX SUBCUTANEOUS INJECTABLE 2 *VAGINAL AND RELATED PRODUCTS* *IMIDAZOLE-RELATED ANTIFUNGALS*** miconazole 3 vaginal suppository 1 or 1b* terconazole vaginal cream 1 or 1b* QL terconazole vaginal suppository 1 or 1b* QL *SPERMICIDES*** ENCARE VAGINAL SUPPOSITORY 2 $0 OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 2 $0 TODAY SPONGE VAGINAL 2 $0 VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 2 $0 *VAGINAL ANTI- INFECTIVES*** CLEOCIN VAGINAL SUPPOSITORY 2 clindamycin phosphate vaginal cream 1 or 1b* metronidazole vaginal gel 1 or 1b* VANDAZOLE VAGINAL GEL 1 or 1b* *VAGINAL ESTROGENS*** estradiol vaginal cream 1 or 1b* QL estradiol vaginal tablet 1 or 1b* QL PREMARIN VAGINAL CREAM 2 QL yuvafem vaginal tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 90