Drug Name Tier Notes fosaprepitant dimeglumine intravenous solution reconstituted 2 LD; QL *ANTIFUNGALS* *ANTIFUNGALS*** amphotericin b intravenous solution reconstituted 2 amphotericin b liposome intravenous suspension reconstituted 2 flucytosine oral capsule 2 PA griseofulvin microsize oral suspension 1 or 1b* griseofulvin microsize oral tablet 1 or 1b* griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 or 1b* nystatin oral tablet 1 or 1b* terbinafine hcl oral tablet 1 or 1b* *IMIDAZOLES*** ketoconazole oral tablet 1 or 1b* QL *TRIAZOLES*** fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400- 0.9 mg/200ml-% 1 or 1b* fluconazole oral suspension reconstituted 1 or 1b* QL fluconazole oral tablet 1 or 1b* QL itraconazole oral capsule 2 PA; QL itraconazole oral solution 2 PA; QL posaconazole intravenous solution 2 posaconazole oral suspension 2 PA; QL posaconazole oral tablet delayed release 2 PA; QL voriconazole oral suspension reconstituted 2 PA; QL voriconazole oral tablet 2 PA; QL *ANTIHISTAMINES* *ANTIHISTAMINES - ETHANOLAMINES*** carbinoxamine maleate er oral suspension extended release 1 or 1b* ST; QL carbinoxamine maleate oral solution 1 or 1b* ST Drug Name Tier Notes carbinoxamine maleate oral tablet 4 mg 1 or 1b* ST clemastine fumarate oral tablet 2.68 mg 1 or 1b* ST; QL diphenhydramine hcl injection solution 2 *ANTIHISTAMINES - NON-SEDATING*** cetirizine hcl oral solution 1 or 1b* BE; QL desloratadine oral tablet 3 QL desloratadine oral tablet dispersible 3 QL levocetirizine dihydrochloride oral tablet 1 or 1b* BE; QL *ANTIHISTAMINES - PHENOTHIAZINES*** promethazine hcl injection solution 1 or 1a* promethazine hcl oral solution 1 or 1a* QL promethazine hcl oral tablet 1 or 1a* QL promethazine hcl rectal suppository 12.5 mg, 25 mg 2 QL promethegan rectal suppository 2 QL *ANTIHISTAMINES - PIPERIDINES*** cyproheptadine hcl oral syrup 1 or 1b* cyproheptadine hcl oral tablet 1 or 1b* *ANTIHYPERLIPIDEMI CS* *ANTIHYPERLIPIDEMI CS - MISC.*** icosapent ethyl oral capsule 2 PA; QL omega-3-acid ethyl esters oral capsule 1 or 1b* PA; QL VASCEPA ORAL CAPSULE 2 PA; QL *BILE ACID SEQUESTRANTS*** cholestyramine light oral packet 2 QL cholestyramine light oral powder 2 QL cholestyramine oral packet 2 QL cholestyramine oral powder 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 26