Drug Name Tier Notes sm nicotine polacrilex mouth/throat gum 4 mg 1 or 1b* $0 thrive mouth/throat gum 2 mg 1 or 1b* $0 varenicline tartrate (starter) oral tablet therapy pack 2 $0; QL varenicline tartrate oral tablet 0.5 mg, 1 mg 2 $0; QL varenicline tartrate(continue) oral tablet 2 $0; QL *SPHINGOSINE 1- PHOSPHATE (S1P) RECEPTOR MODULATORS*** fingolimod hcl oral capsule 4 PA; LD; QL; SP MAYZENT ORAL TABLET 4 PA; LD; QL; SP MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 PA; LD; QL; SP ZEPOSIA ORAL CAPSULE 4 PA; LD; QL; SP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 0.23MG &0.46MG 0.92MG(21) 4 PA; LD; QL; SP *THIENBENZODIAZEPI NES & SSRIS*** olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 1 or 1b* AL; QL olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 1 or 1b* DO; AL *VASOMOTOR SYMPTOM AGENTS - SSRIS*** paroxetine mesylate oral capsule 1 or 1b* *RESPIRATORY AGENTS - MISC.* *CYSTIC FIBROSIS AGENT - COMBINATIONS*** TRIKAFTA ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP Drug Name Tier Notes TRIKAFTA ORAL THERAPY PACK 4 PA; LD; QL; SP *HYDROLYTIC ENZYMES*** PULMOZYME INHALATION SOLUTION 2.5 MG/2.5ML 4 PA; LD; QL; SP *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** OFEV ORAL CAPSULE 4 PA; LD; QL; SP *PULMONARY FIBROSIS AGENTS*** pirfenidone oral capsule 4 PA; LD; QL; SP pirfenidone oral tablet 267 mg, 801 mg 4 PA; LD; QL; SP pirfenidone oral tablet 534 mg 4 PA; LD; QL *SULFONAMIDES* *SULFONAMIDES*** sulfadiazine oral tablet 2 *TETRACYCLINES* *TETRACYCLINES*** demeclocycline hcl oral tablet 2 doxy 100 intravenous solution reconstituted 2 QL doxycycline hyclate intravenous solution reconstituted 2 QL doxycycline hyclate oral capsule 1 or 1b* QL doxycycline hyclate oral tablet 100 mg, 20 mg 1 or 1b* QL doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 or 1b* QL doxycycline monohydrate oral capsule 150 mg 3 ST; QL doxycycline monohydrate oral suspension reconstituted 1 or 1b* QL doxycycline monohydrate oral tablet 1 or 1b* QL minocycline hcl oral capsule 1 or 1b* QL minocycline hcl oral tablet 1 or 1b* QL mondoxyne nl oral capsule 100 mg 1 or 1b* QL tetracycline hcl oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 85