Drug Name Tier Notes fluorouracil external solution 1 or 1b* AL; QL *ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID'S*** diclofenac sodium external gel 3 % 2 PA; QL *ANTIPRURITICS - TOPICAL*** doxepin hcl external cream 2 PA; QL *ANTIPSORIATICS - SYSTEMIC*** acitretin oral capsule 2 QL COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML 4 PA; LD; QL; SP COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP COSENTYX UNOREADY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP methoxsalen rapid oral capsule 4 LD; SP SELARSDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; QL; SP SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 4 PA; LD; QL; SP Drug Name Tier Notes STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP TALTZ SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP TREMFYA ONE-PRESS SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP TREMFYA PEN SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/ML 4 PA; LD; QL; SP TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML 4 PA; LD; QL; SP *ANTIPSORIATICS*** calcipotriene external cream 1 or 1b* QL calcipotriene external foam 3 ST; QL calcipotriene external ointment 1 or 1b* QL calcipotriene external solution 1 or 1b* QL calcitrene external ointment 1 or 1b* QL calcitriol external ointment 1 or 1b* QL tazarotene external cream 1 or 1b* QL tazarotene external gel 2 QL *ANTISEBORRHEIC PRODUCTS*** selenium sulfide external lotion 1 or 1a* QL *ANTIVIRALS - TOPICAL*** acyclovir external cream 1 or 1b* PA; QL acyclovir external ointment 1 or 1b* QL penciclovir external cream 2 PA; QL *ATOPIC DERMATITIS - JANUS KINASE (JAK) INHIBITORS*** OPZELURA EXTERNAL CREAM 3 PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 48