Drug Name Tier Notes levofloxacin oral solution 2 levofloxacin oral tablet 1 or 1b* moxifloxacin hcl oral tablet 2 ofloxacin oral tablet 300 mg, 400 mg 1 or 1b* *GASTROINTESTINAL AGENTS - MISC.* *GALLSTONE SOLUBILIZING AGENTS*** ursodiol oral capsule 300 mg 2 ursodiol oral tablet 2 *GASTROINTESTINAL ANTIALLERGY AGENTS*** cromolyn sodium oral concentrate 1 or 1b* *GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS*** lubiprostone oral capsule 2 QL *GASTROINTESTINAL STIMULANTS*** metoclopramide hcl injection solution 1 or 1a* metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml 1 or 1a* QL metoclopramide hcl oral tablet 1 or 1a* QL metoclopramide hcl oral tablet dispersible 5 mg 1 or 1a* QL *IBS AGENT - GUANYLATE CYCLASE- C (GC-C) AGONISTS*** LINZESS ORAL CAPSULE 2 QL *IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS*** alosetron hcl oral tablet 2 PA; QL *INFLAMMATORY BOWEL AGENTS*** balsalazide disodium oral capsule 1 or 1b* QL mesalamine er oral capsule extended release 24 hour 2 QL Drug Name Tier Notes mesalamine oral capsule delayed release 2 QL mesalamine oral tablet delayed release 2 QL mesalamine rectal enema 2 QL mesalamine rectal suppository 2 QL mesalamine-cleanser rectal kit 2 QL PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG 2 QL sulfasalazine oral tablet 1 or 1b* QL sulfasalazine oral tablet delayed release 1 or 1b* QL *INTEGRIN RECEPTOR ANTAGONISTS*** ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *INTERLEUKIN ANTAGONISTS*** SELARSDI INTRAVENOUS SOLUTION 4 PA; QL; SP SKYRIZI INTRAVENOUS SOLUTION 4 PA; LD; QL; SP SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE 4 PA; LD; QL; SP STELARA INTRAVENOUS SOLUTION 4 PA; LD; QL; SP TREMFYA CROHNS INDUCTION SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; QL; SP TREMFYA INTRAVENOUS SOLUTION 4 PA; QL; SP TREMFYA PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 200 MG/2ML 4 PA; QL; SP TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/2ML 4 PA; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 55