Drug Name Tier Notes HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 2 QL HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL HUMULIN N SUBCUTANEOUS SUSPENSION 2 QL HUMULIN R INJECTION SOLUTION 2 QL HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 2 PA; QL HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 PA; QL INSULIN LISPRO (1 UNIT DIAL) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 ST; QL INSULIN LISPRO INJECTION SOLUTION 2 QL INSULIN LISPRO JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS SUSPENSION PEN- INJECTOR 2 QL LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL LANTUS SUBCUTANEOUS SOLUTION 2 QL LYUMJEV INJECTION SOLUTION 2 QL LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL Drug Name Tier Notes TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 QL TRESIBA SUBCUTANEOUS SOLUTION 2 QL *INCRETIN MIMETIC AGENTS (GIP & GLP-1 RECEPTOR AGONISTS)*** MOUNJARO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; QL *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** liraglutide subcutaneous solution pen-injector 2 PA; QL OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 MG/3ML 2 PA; QL OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 4 MG/3ML 2 PA; QL OZEMPIC (2 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 PA; QL RYBELSUS ORAL TABLET 2 PA; QL TRULICITY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 23