Drug Name Tier Notes WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 $0 *GLUCOSE MONITORING TEST SUPPLIES*** ACCU-CHEK FASTCLIX LANCET KIT 2 QL ACCU-CHEK FASTCLIX LANCETS 2 QL ACCU-CHEK SAFE-T PRO LANCETS 2 QL ACCU-CHEK SOFTCLIX LANCET DEV KIT 2 QL ACCU-CHEK SOFTCLIX LANCETS 2 QL COAGUCHEK LANCETS 2 QL DEXCOM G6 RECEIVER DEVICE 2 PA; QL DEXCOM G6 SENSOR 2 PA; QL DEXCOM G6 TRANSMITTER 2 PA; QL DEXCOM G7 RECEIVER DEVICE 2 PA; QL DEXCOM G7 SENSOR 2 PA; QL FREESTYLE LANCETS 2 QL FREESTYLE LIBRE 14 DAY READER DEVICE 2 PA; QL FREESTYLE LIBRE 14 DAY SENSOR 2 PA; QL FREESTYLE LIBRE 2 PLUS SENSOR 2 PA; QL Drug Name Tier Notes FREESTYLE LIBRE 2 READER DEVICE 2 PA; QL FREESTYLE LIBRE 2 SENSOR 2 PA; QL FREESTYLE LIBRE 3 PLUS SENSOR 2 PA; QL FREESTYLE LIBRE 3 READER DEVICE 2 PA; QL FREESTYLE LIBRE 3 SENSOR 2 PA; QL FREESTYLE LIBRE READER DEVICE 2 PA; QL FREESTYLE UNISTICK II LANCETS 2 QL *INSULIN ADMINISTRATION SUPPLIES*** OMNIPOD 5 DEXG7G6 INTRO GEN 5 KIT 2 PA; QL OMNIPOD 5 DEXG7G6 PODS GEN 5 2 PA; QL OMNIPOD 5 LIBRE2 G6 INTRO G5 KIT 2 PA; QL OMNIPOD 5 LIBRE2 PLUS G6 PODS 2 PA; QL OMNIPOD DASH INTRO (GEN 4) KIT 2 PA; QL OMNIPOD DASH PDM (GEN 4) KIT 2 PA; QL OMNIPOD DASH PODS (GEN 4) 2 PA; QL TWIIST REFILL KIT KIT 2 PA; QL TWIIST REFILL KIT/INFUSION SET KIT 2 PA; QL TWIIST STARTER KIT KIT 2 PA; QL *NEEDLES & SYRINGES*** 1ST TIER UNIFINE PENTIPS 3 ST; QL 1ST TIER UNIFINE PENTIPS PLUS 3 ST; QL ADVOCATE INSULIN PEN NEEDLE 3 ST; QL ADVOCATE INSULIN PEN NEEDLES 3 ST; QL ADVOCATE INSULIN SYRINGE 3 ST; QL aq insulin syringe 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 63