Drug Name Tier Notes *SELECTIVE VASOPRESSIN V2- RECEPTOR ANTAGONISTS*** tolvaptan oral tablet 4 PA; LD; QL; SP tolvaptan oral tablet therapy pack 4 PA; LD; QL *SOMATOSTATIC AGENTS*** LANREOTIDE ACETATE SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP *UREA CYCLE DISORDER - AGENTS*** PHEBURANE ORAL PELLET 4 PA; LD; QL; SP sodium phenylbutyrate oral powder 3 gm/tsp 4 PA; LD; QL; SP sodium phenylbutyrate oral tablet 4 PA; LD; QL; SP *VASOPRESSIN*** desmopressin ace spray refrig nasal solution 1 or 1b* desmopressin acetate injection solution 1 or 1b* LD desmopressin acetate oral tablet 1 or 1b* LD; QL desmopressin acetate pf injection solution 1 or 1b* LD desmopressin acetate spray nasal solution 1 or 1b* vasopressin +rfid intravenous solution 2 vasopressin intravenous solution 2 *ESTROGENS* *ESTROGEN & PROGESTIN*** ABIGALE LO ORAL TABLET 1 or 1b* BIJUVA ORAL CAPSULE 2 QL CLIMARA PRO TRANSDERMAL PATCH WEEKLY 2 QL Drug Name Tier Notes COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 2 QL estradiol-norethindrone acet oral tablet 1 or 1b* fyavolv oral tablet 1 or 1b* jinteli oral tablet 1 or 1b* mimvey oral tablet 1 or 1b* norethindrone-eth estradiol oral tablet 1 or 1b* PREMPHASE ORAL TABLET 2 PREMPRO ORAL TABLET 2 *ESTROGENS*** dotti transdermal patch twice weekly 1 or 1b* QL estradiol oral tablet 1 or 1b* estradiol transdermal gel 2 QL estradiol transdermal patch twice weekly 1 or 1b* QL estradiol transdermal patch weekly 1 or 1b* QL estradiol valerate intramuscular oil 1 or 1b* EVAMIST TRANSDERMAL SOLUTION 2 QL lyllana transdermal patch twice weekly 1 or 1b* QL MENEST ORAL TABLET 2 PREMARIN INJECTION SOLUTION RECONSTITUTED 2 PREMARIN ORAL TABLET 2 QL *FLUOROQUINOLONES * *FLUOROQUINOLONES *** ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg 1 or 1b* ciprofloxacin in d5w intravenous solution 2 levofloxacin in d5w intravenous solution 2 levofloxacin intravenous solution 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 54