Drug Name Tier Notes *ANTIDOTES AND SPECIFIC ANTAGONISTS* *ANTIDOTES - CHELATING AGENTS*** deferasirox granules oral packet 4 PA; LD; SP deferasirox oral packet 4 PA; LD; SP deferasirox oral tablet 4 PA; LD; SP deferasirox oral tablet soluble 4 PA; LD; SP deferiprone oral tablet 4 PA; LD *ANTIDOTES AND SPECIFIC ANTAGONISTS*** acetylcysteine intravenous solution 2 fomepizole intravenous solution 1.5 gm/1.5ml 1 or 1b* methylene blue (antidote) intravenous solution 1 or 1b* methylene blue intravenous solution 50 mg/10ml 1 or 1b* SODIUM THIOSULFATE INTRAVENOUS SOLUTION 250 MG/ML 1 or 1b* *BENZODIAZEPINE ANTAGONISTS*** flumazenil intravenous solution 1 or 1b* *OPIOID ANTAGONISTS*** KLOXXADO NASAL LIQUID 2 QL naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 or 1b* QL naloxone hcl injection solution cartridge 1 or 1b* QL naloxone hcl injection solution prefilled syringe 1 or 1b* QL naloxone hcl nasal liquid 1 or 1b* QL naltrexone hcl oral tablet 1 or 1b* OPVEE NASAL SOLUTION 2 QL REXTOVY NASAL LIQUID 2 QL Drug Name Tier Notes ZIMHI INJECTION SOLUTION PREFILLED SYRINGE 2 QL *ANTIEMETICS* *5-HT3 RECEPTOR ANTAGONISTS*** granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml 2 LD granisetron hcl oral tablet 2 LD; QL ondansetron hcl +rfid injection solution 2 ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml 2 ondansetron hcl injection solution prefilled syringe 2 LD ondansetron hcl oral solution 2 LD; QL ondansetron hcl oral tablet 2 LD; QL ondansetron oral tablet dispersible 16 mg 2 QL ondansetron oral tablet dispersible 4 mg, 8 mg 2 LD; QL palonosetron hcl intravenous solution 0.25 mg/5ml 2 LD palonosetron hcl intravenous solution prefilled syringe 2 LD *ANTIEMETIC COMBINATIONS*** doxylamine-pyridoxine oral tablet delayed release 1 or 1b* PA; QL *ANTIEMETICS - ANTICHOLINERGIC*** meclizine hcl oral tablet 25 mg 1 or 1a* meclizine hcl oral tablet 50 mg 1 or 1b* scopolamine transdermal patch 72 hour 1 or 1b* trimethobenzamide hcl oral capsule 1 or 1b* *ANTIEMETICS - MISCELLANEOUS*** dronabinol oral capsule 2 QL *SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS*** aprepitant oral 2 LD; QL aprepitant oral capsule 2 LD; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 25