Drug Name Tier Notes *MISC. ANTI-ULCER*** sucralfate oral suspension 2 sucralfate oral tablet 1 or 1b* *PROTON PUMP INHIBITORS*** esomeprazole magnesium oral capsule delayed release 40 mg 1 or 1b* esomeprazole magnesium oral packet 1 or 1b* lansoprazole oral capsule delayed release 15 mg 1 or 1b* BE lansoprazole oral capsule delayed release 30 mg 1 or 1b* omeprazole oral capsule delayed release 1 or 1b* pantoprazole sodium oral tablet delayed release 1 or 1b* *QUATERNARY ANTICHOLINERGICS*** glycopyrrolate injection solution 1 or 1b* glycopyrrolate oral solution 2 glycopyrrolate oral tablet 1 mg, 2 mg 1 or 1b* glycopyrrolate pf +rfid injection solution prefilled syringe 1 or 1b* GLYCOPYRROLATE PF INJECTION SOLUTION PREFILLED SYRINGE 0.2 MG/ML, 0.4 MG/2ML 1 or 1b* methscopolamine bromide oral tablet 1 or 1b* *ULCER ANTI- INFECTIVE W/ BISMUTH COMBINATIONS*** bis subcit-metronid-tetracyc oral capsule 2 ST; QL bismuth/metronidaz/tetracycl in oral capsule 2 ST; QL *ULCER DRUGS - PROSTAGLANDINS*** misoprostol oral tablet 1 or 1a* Drug Name Tier Notes *URINARY ANTISPASMODICS* *URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)** * darifenacin hydrobromide er oral tablet extended release 24 hour 2 QL fesoterodine fumarate er oral tablet extended release 24 hour 2 QL oxybutynin chloride er oral tablet extended release 24 hour 1 or 1b* QL oxybutynin chloride oral solution 1 or 1b* QL oxybutynin chloride oral tablet 1 or 1b* QL solifenacin succinate oral tablet 2 QL tolterodine tartrate er oral capsule extended release 24 hour 1 or 1b* QL tolterodine tartrate oral tablet 1 or 1b* QL trospium chloride er oral capsule extended release 24 hour 2 QL trospium chloride oral tablet 2 QL *URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS*** mirabegron er oral tablet extended release 24 hour 2 QL MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER 3 PA; QL *URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS*** bethanechol chloride oral tablet 2 *URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS*** flavoxate hcl oral tablet 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 87