Quick facts
Tier 1 - Generic
Tier 1
Tier 2 - Preferred brand
Tier 2
Tier 3 - Non-preferred brand
Tier 3
Tier 4 - Specialty
Tier 4
metformin (generic)
Tier 1
Jardiance (empagliflozin)
Tier 2
insulin glargine (Basaglar)
Tier 2
Wegovy (semaglutide injection)
Tier 4, PA required, QL applies
More details (7)
phentermine (generic)
Tier 1
atorvastatin (generic Lipitor)
Tier 1
rosuvastatin (generic Crestor)
Tier 1
Entresto (sacubitril/valsartan)
Tier 2, PA required
Humira (adalimumab)
Tier 4, PA required
Hadlima (adalimumab-bwwd biosimilar)
Tier 4, PA required
Ozempic (semaglutide injection)
Tier 2, PA required
Carrier contact
1-800-555-0142 — member services
Your member ID card: check the carrier website or app, or ask HR for a copy.
Confirm details with your carrier for current plan information.