Drug Name Tier Notes clindamycin phos (once- daily) external gel 1 or 1b* QL clindamycin phos (twice- daily) external gel 1 or 1b* QL clindamycin phosphate external foam 1 or 1b* QL clindamycin phosphate external lotion 1 or 1b* QL clindamycin phosphate external solution 1 or 1b* QL clindamycin phosphate external swab 1 or 1b* QL dapsone external gel 3 ST; QL ery external pad 1 or 1b* QL erythromycin external gel 1 or 1b* QL erythromycin external solution 1 or 1b* QL sulfacetamide sodium (acne) external lotion 1 or 1b* *ACNE COMBINATIONS*** adapalene-benzoyl peroxide external gel 1 or 1b* PA; QL benzoyl peroxide- erythromycin external gel 1 or 1b* QL clindamycin phos-benzoyl perox external gel 1.2-3.75 % 2 QL clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1.2-5 % 1 or 1b* QL clindamycin-tretinoin external gel 3 PA; QL neuac external gel 1 or 1b* QL *ACNE PRODUCTS*** accutane oral capsule 2 PA adapalene external cream 1 or 1b* PA; QL adapalene external gel 0.3 % 1 or 1b* PA; QL adapalene external pad 1 or 1b* PA; QL amnesteem oral capsule 10 mg, 20 mg, 40 mg 2 PA AMNESTEEM ORAL CAPSULE 30 MG 2 PA claravis oral capsule 2 PA isotretinoin oral capsule 2 PA tretinoin external cream 1 or 1b* PA; QL tretinoin external gel 1 or 1b* PA; QL Drug Name Tier Notes tretinoin microsphere external gel 0.04 %, 0.1 % 1 or 1b* PA; QL tretinoin microsphere pump external gel 0.04 %, 0.1 % 1 or 1b* PA; QL zenatane oral capsule 2 PA *ANTIBIOTICS - TOPICAL*** gentamicin sulfate external cream 1 or 1b* QL gentamicin sulfate external ointment 1 or 1b* QL mupirocin external ointment 1 or 1b* QL *ANTIFUNGALS - TOPICAL COMBINATIONS*** clotrimazole-betamethasone external cream 1 or 1b* QL clotrimazole-betamethasone external lotion 1 or 1b* QL nystatin-triamcinolone external cream 1 or 1b* QL nystatin-triamcinolone external ointment 1 or 1b* QL *ANTIFUNGALS - TOPICAL*** ciclodan external solution 1 or 1b* QL ciclopirox external gel 1 or 1b* QL ciclopirox external shampoo 1 or 1b* QL ciclopirox external solution 1 or 1b* QL ciclopirox olamine external cream 1 or 1b* QL ciclopirox olamine external suspension 1 or 1b* QL KLAYESTA EXTERNAL POWDER 1 or 1b* QL naftifine hcl external cream 2 ST; QL naftifine hcl external gel 2 % 2 ST; QL nyamyc external powder 1 or 1b* QL nystatin external cream 1 or 1b* QL nystatin external ointment 1 or 1b* QL nystatin external powder 1 or 1b* QL nystop external powder 1 or 1b* QL *ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL*** fluorouracil external cream 5 % 1 or 1b* AL; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 47