NOVOTWIST PEN NEEDLE FREESTYLE LIBRE 2 SENSOR NOVOTWIST/NOVOFINE PEN NEEDLE FREESTYLE LIBRE 3 SENSOR FREESTYLE LIBRE 3 RECEIVER FREESTYLE LIBRE RECEIVER FREESTYLE LIBRE SENSOR (14-DAY) OMNIPOD STARTER KIT OMNIPOD GO KIT OMNIPOD DASH INTRO KIT OMNIPOD 5 INTRO KIT OMNIPOD 5 PACK PODS OMNIPOD 5 G7 INTRO KIT OMNIPOD 5 G7 PODS ONETOUCH TEST STRIP ONETOUCH VERIO TEST STRIP V-GO INJ KIT EMOTIONAL HEALTH Tier 1 Tier 2 Tier 3 citalopram soln / tab CELEXA TAB escitalopram soln / tab LEXAPRO SOLN / TAB fluoxetine soln / cap / tab LUVOX CR CAP fluvoxamine ER cap PAXIL CR TAB fluvoxamine tab PAXIL SUSP / TAB paroxetine ER tab PROZAC SOLN / CAP / TAB paroxetine oral susp / tab ZOLOFT CONC / TAB sertraline conc / tab Page 5 of 10