Drug Name Tier Notes pacerone oral tablet 200 mg 1 or 1b* QL *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ADRENERGIC COMBINATIONS*** ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/ACT 2 QL BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/ACT, 200-25 MCG/ACT, 50-25 MCG/INH 2 QL BREYNA INHALATION AEROSOL 1 or 1b* QL BREZTRI AEROSPHERE INHALATION AEROSOL 2 QL budesonide-formoterol fumarate inhalation aerosol 1 or 1b* QL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 QL fluticasone furoate-vilanterol inhalation aerosol powder breath activated 100-25 mcg/act, 200-25 mcg/act 2 QL fluticasone-salmeterol inhalation aerosol 1 or 1b* QL fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 113-14 mcg/act, 232-14 mcg/act, 250-50 mcg/act, 500-50 mcg/act, 55- 14 mcg/act 1 or 1b* QL ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 or 1b* QL STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT 2 QL TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/ACT, 200-62.5-25 MCG/ACT 2 QL Drug Name Tier Notes umeclidinium-vilanterol inhalation aerosol powder breath activated 1 or 1b* QL wixela inhub inhalation aerosol powder breath activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act 1 or 1b* QL *ANTI-IGE MONOCLONAL ANTIBODIES*** XOLAIR SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *ANTI- INFLAMMATORY AGENTS*** cromolyn sodium inhalation nebulization solution 1 or 1b* *BETA ADRENERGICS*** albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act 1 or 1b* QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml 1 or 1b* QL ALBUTEROL SULFATE INHALATION NEBULIZATION SOLUTION (5 MG/ML) 0.5% 1 or 1b* QL albuterol sulfate oral syrup 1 or 1b* albuterol sulfate oral tablet 1 or 1b* arformoterol tartrate inhalation nebulization solution 2 QL formoterol fumarate inhalation nebulization solution 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 16