Drug Name Tier Notes sodium fluoride 5000 plus dental cream 1 or 1b* QL sodium fluoride 5000 ppm dental cream 1 or 1b* QL sodium fluoride 5000 ppm dental gel 1 or 1b* QL sodium fluoride 5000 ppm dental paste 1 or 1b* QL sodium fluoride dental cream 1 or 1b* QL sodium fluoride mouth/throat solution 1 or 1a* *SALIVA STIMULANTS*** cevimeline hcl oral capsule 2 pilocarpine hcl oral tablet 2 QL *STEROIDS - MOUTH/THROAT/DENT AL*** KOURZEQ MOUTH/THROAT PASTE 1 or 1b* oralone mouth/throat paste 1 or 1b* triamcinolone acetonide mouth/throat paste 1 or 1b* *MULTIVITAMINS* *B-COMPLEX VITAMINS*** b complex-b12 oral tablet 1 or 1b* $0 b-complex plus b-12 oral tablet 1 or 1b* $0 b-complex/b-12 oral tablet 1 or 1b* $0 ra b-complex oral tablet 1 or 1b* $0 ra b-complex with b-12 oral tablet 1 or 1b* $0 vitamin b complex oral tablet 1 or 1b* $0 vitamin b complex w/b-12 oral tablet 1 or 1b* $0 vitamin-b complex oral tablet 1 or 1b* $0 *B-COMPLEX W/ C & CALCIUM*** gnp b-complex plus vitamin c oral tablet 1 or 1b* $0 qc b-complex/vitamin c oral tablet 1 or 1b* $0 *B-COMPLEX W/ C & FOLIC ACID*** b complex-c-folic acid oral tablet 1 or 1b* $0 Drug Name Tier Notes b-complex balanced oral tablet 1 or 1b* $0 b-complex/vitamin c oral tablet 1 or 1b* $0 b-complex-c (w/folic acid) oral tablet 1 or 1b* $0 b-plex oral tablet 1 or 1b* $0 dialyvite 800 oral tablet 1 or 1b* $0 eql super b complex/vitamin c oral tablet 1 or 1b* $0 FULL SPECTRUM B/VITAMIN C ORAL TABLET 1 or 1b* $0 kp b complex-c oral tablet 1 or 1b* $0 nephro vitamins oral tablet 1 or 1b* $0 NEPHRO-VITE ORAL TABLET 1 or 1b* $0 renal vitamin oral tablet 1 or 1b* $0 rena-vite oral tablet 1 or 1b* $0 stress formula (folic acid) oral tablet 1 or 1b* $0 super b complex/fa/vit c oral tablet 1 or 1b* $0 super b-complex/vit c/fa oral tablet 1 or 1b* $0 *B-COMPLEX W/ C*** allbee/c oral tablet 1 or 1b* $0 b complex-c oral tablet 1 or 1b* $0 b-complex-c oral tablet 1 or 1b* $0 better b complex oral tablet 1 or 1b* $0 cvs b complex plus c oral tablet 1 or 1b* $0 cvs super b complex/c oral tablet 1 or 1b* $0 ft b-complex plus vitamin c oral tablet 1 or 1b* $0 super b complex/vitamin c oral tablet 1 or 1b* $0 super b-complex + vitamin c oral tablet 1 or 1b* $0 *B-COMPLEX W/ C- BIOTIN-E & FOLIC ACID*** B COMPLEX-C-BIOTIN- E-FA ORAL TABLET 2 $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 73