Drug Name Tier Notes penicillin g sodium injection solution reconstituted 2 penicillin v potassium oral solution reconstituted 1 or 1b* penicillin v potassium oral tablet 1 or 1b* pfizerpen injection solution reconstituted 2 *PENICILLIN COMBINATIONS*** amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1 or 1b* amoxicillin-pot clavulanate oral suspension reconstituted 1 or 1b* amoxicillin-pot clavulanate oral tablet 1 or 1b* ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm 2 ampicillin-sulbactam sodium intravenous solution reconstituted 2 AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125- 31.25 MG/5ML 2 piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3- 0.375 gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36- 4.5) gm 2 *PENICILLINASE- RESISTANT PENICILLINS*** dicloxacillin sodium oral capsule 1 or 1b* nafcillin sodium injection solution reconstituted 1 gm, 2 gm 2 nafcillin sodium intravenous solution reconstituted 10 gm 2 oxacillin sodium injection solution reconstituted 1 gm, 2 gm 2 oxacillin sodium intravenous solution reconstituted 2 Drug Name Tier Notes *PROGESTINS* *PROGESTINS*** GALLIFREY ORAL TABLET 1 or 1b* medroxyprogesterone acetate oral tablet 1 or 1a* QL megestrol acetate oral suspension 625 mg/5ml 1 or 1b* norethindrone acetate oral tablet 1 or 1b* progesterone intramuscular oil 1 or 1b* progesterone oral capsule 1 or 1b* QL *PSYCHOTHERAPEUTI C AND NEUROLOGICAL AGENTS - MISC.* *AGENTS FOR OPIOID WITHDRAWAL*** lofexidine hcl oral tablet 2 QL *ALCOHOL DETERRENTS*** acamprosate calcium oral tablet delayed release 2 QL disulfiram oral tablet 1 or 1b* *ANTI-CATAPLECTIC AGENTS*** sodium oxybate oral solution 4 PA; LD; QL *ANTIDEMENTIA AGENT COMBINATIONS*** memantine hcl-donepezil hcl oral capsule extended release 24 hour 2 QL *BENZODIAZEPINES & TRICYCLIC AGENTS*** chlordiazepoxide- amitriptyline oral tablet 1 or 1b* *CHOLINOMIMETICS - ACHE INHIBITORS*** donepezil hcl oral tablet 10 mg, 23 mg 1 or 1b* QL donepezil hcl oral tablet 5 mg 1 or 1b* DO donepezil hcl oral tablet dispersible 1 or 1b* QL galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 81