Drug Name Tier Notes *ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS*** SAXENDA SUBCUTANEOUS SOLUTION PEN- INJECTOR 3 PA; BE; QL WEGOVY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; BE; QL *HISTAMINE H3- RECEPTOR ANTAGONIST/INVERSE AGONISTS*** WAKIX ORAL TABLET 17.8 MG 4 PA; LD; QL; SP WAKIX ORAL TABLET 4.45 MG 4 PA; LD; DO; SP *LIPASE INHIBITORS*** orlistat oral capsule 2 PA; BE; QL *STIMULANTS - MISC.*** armodafinil oral tablet 2 PA; QL dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg 1 or 1b* ST; DO dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg 1 or 1b* ST; QL dexmethylphenidate hcl er oral capsule extended release 24 hour 30 mg, 35 mg, 40 mg 1 or 1b* PA; QL dexmethylphenidate hcl er oral capsule extended release 24 hour 5 mg 1 or 1b* PA; DO dexmethylphenidate hcl oral tablet 10 mg 1 or 1b* PA; QL dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg 1 or 1b* PA; DO methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 mg 1 or 1b* PA; QL Drug Name Tier Notes methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg 1 or 1b* PA; DO methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg, 40 mg, 60 mg 1 or 1b* PA; QL methylphenidate hcl er (osm) oral tablet extended release 18 mg, 27 mg 1 or 1b* PA; DO methylphenidate hcl er (osm) oral tablet extended release 36 mg, 45 mg, 54 mg, 63 mg 1 or 1b* PA; QL METHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED RELEASE 72 MG 1 or 1b* PA; QL methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg 1 or 1b* PA; DO methylphenidate hcl er (xr) oral capsule extended release 24 hour 40 mg, 50 mg, 60 mg 1 or 1b* PA; QL methylphenidate hcl er oral tablet extended release 10 mg 1 or 1b* PA; DO methylphenidate hcl er oral tablet extended release 20 mg 1 or 1b* PA; QL methylphenidate hcl er oral tablet extended release 24 hour 1 or 1b* PA; DO methylphenidate hcl oral solution 1 or 1b* PA; QL methylphenidate hcl oral tablet 10 mg, 5 mg 1 or 1b* PA; DO methylphenidate hcl oral tablet 20 mg 1 or 1b* PA; QL methylphenidate hcl oral tablet chewable 10 mg 1 or 1b* PA; QL methylphenidate hcl oral tablet chewable 2.5 mg 1 or 1b* ST; DO methylphenidate hcl oral tablet chewable 5 mg 1 or 1b* PA; DO methylphenidate transdermal patch 10 mg/9hr, 15 mg/9hr 2 ST; DO methylphenidate transdermal patch 20 mg/9hr, 30 mg/9hr 2 ST; QL modafinil oral tablet 100 mg 2 PA; DO modafinil oral tablet 200 mg 2 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 8