Drug Name Tier Notes *PULM HYPERTEN- SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)*** ADEMPAS ORAL TABLET 4 PA; LD; QL; SP *PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS*** ambrisentan oral tablet 4 PA; LD; QL; SP bosentan oral tablet 4 PA; LD; QL; SP OPSUMIT ORAL TABLET 4 PA; LD; QL; SP TRACLEER ORAL TABLET SOLUBLE 4 PA; LD; QL; SP *PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS*** alyq oral tablet 4 PA; LD; QL; SP sildenafil citrate oral suspension reconstituted 4 PA; LD; QL; SP sildenafil citrate oral tablet 20 mg 4 PA; LD; QL; SP tadalafil (pah) oral tablet 4 PA; LD; QL; SP *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** UPTRAVI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL UPTRAVI ORAL TABLET 4 PA; LD; QL; SP *SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS*** sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* PA tadalafil oral tablet 10 mg, 20 mg 1 or 1b* PA tadalafil oral tablet 2.5 mg, 5 mg 1 or 1b* PA; QL vardenafil hcl oral tablet dispersible 1 or 1b* PA Drug Name Tier Notes *SEPTAL AGENTS - ABLATION** dehydrated alcohol intra- arterial solution 2 *SINUS NODE INHIBITORS** ivabradine hcl oral tablet 2 PA; QL *CEPHALOSPORINS* *CEPHALOSPORINS - 1ST GENERATION*** cefadroxil oral capsule 1 or 1b* cefadroxil oral suspension reconstituted 1 or 1b* cefadroxil oral tablet 1 or 1b* cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 3 gm, 500 mg 2 cefazolin sodium intravenous solution reconstituted 1 gm 2 cephalexin oral capsule 1 or 1a* cephalexin oral suspension reconstituted 1 or 1a* cephalexin oral tablet 1 or 1a* *CEPHALOSPORINS - 2ND GENERATION*** CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12 HOUR 2 cefaclor oral capsule 1 or 1b* cefaclor oral suspension reconstituted 250 mg/5ml 1 or 1b* cefotetan disodium injection solution reconstituted 1 gm, 2 gm 2 cefoxitin sodium intravenous solution reconstituted 2 cefprozil oral suspension reconstituted 1 or 1b* cefprozil oral tablet 1 or 1b* cefuroxime axetil oral tablet 1 or 1b* cefuroxime sodium injection solution reconstituted 750 mg 2 cefuroxime sodium intravenous solution reconstituted 1.5 gm 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 41