Drug Name Tier Notes triazolam oral tablet 1 or 1b* QL *HYPNOTICS - TRICYCLIC AGENTS*** doxepin hcl oral tablet 2 ST; QL *NON- BENZODIAZEPINE - GABA-RECEPTOR MODULATORS*** eszopiclone oral tablet 1 or 1b* QL zaleplon oral capsule 1 or 1b* QL zolpidem tartrate er oral tablet extended release 1 or 1b* QL zolpidem tartrate oral tablet 1 or 1b* QL zolpidem tartrate sublingual tablet sublingual 2 ST; QL *SELECTIVE ALPHA2- ADRENORECEPTOR AGONIST SEDATIVES*** dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml 1 or 1b* dexmedetomidine hcl intravenous solution 200 mcg/2ml 1 or 1b* *SELECTIVE MELATONIN RECEPTOR AGONISTS*** ramelteon oral tablet 2 QL tasimelteon oral capsule 4 PA; LD; QL *LAXATIVES* *BOWEL EVACUANT COMBINATIONS*** GAVILYTE-C ORAL SOLUTION RECONSTITUTED 1 or 1a* $0; QL gavilyte-g oral solution reconstituted 1 or 1a* $0; QL GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 1 or 1a* $0; QL na sulfate-k sulfate-mg sulf oral solution 17.5-3.13-1.6 gm/177ml 1 or 1b* $0; QL peg 3350-kcl-na bicarb-nacl oral solution reconstituted 1 or 1a* $0; QL Drug Name Tier Notes peg-3350/electrolytes oral solution reconstituted 1 or 1a* $0; QL peg- 3350/electrolytes/ascorbat oral solution reconstituted 1 or 1b* $0; QL peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 1 or 1b* $0; QL SUTAB ORAL TABLET 2 QL *LAXATIVES - MISCELLANEOUS*** clearlax oral powder 1 or 1b* $0 constulose oral solution 1 or 1b* QL cvs purelax oral packet 1 or 1b* $0 cvs purelax oral powder 1 or 1b* $0 eq clearlax oral powder 1 or 1b* $0 eq laxative oral packet 1 or 1b* $0 eql clearlax oral powder 1 or 1b* $0 ft clearlax oral powder 1 or 1b* $0 gavilax oral powder 1 or 1b* $0 glycolax oral powder 1 or 1b* $0 gnp clearlax oral packet 1 or 1b* $0 gnp clearlax oral powder 1 or 1b* $0 goodsense clearlax oral powder 1 or 1b* $0 healthylax oral packet 1 or 1b* $0 kls laxaclear oral powder 1 or 1b* $0 KRISTALOSE ORAL PACKET 2 ST; QL LACTULOSE ORAL PACKET 10 GM 2 ST; QL lactulose oral packet 20 gm 2 ST; QL lactulose oral solution 1 or 1b* QL mm clearlax oral powder 1 or 1b* $0 peg 3350 oral packet 1 or 1b* $0 peg 3350 oral powder 1 or 1b* $0 polyethylene glycol 3350 oral packet 17 gm 1 or 1b* $0 polyethylene glycol 3350 oral powder 1 or 1b* $0 qc natura-lax oral powder 1 or 1b* $0 ra laxative oral powder 1 or 1b* $0 sb polyethylene glycol 3350 oral powder 1 or 1b* $0 smooth lax oral packet 1 or 1b* $0 smooth lax oral powder 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 60