Drug Name Tier Notes *OTIC STEROID-ANTI- INFECTIVE COMBINATIONS*** ciprofloxacin-dexamethasone otic suspension 1 or 1b* QL ciprofloxacin-fluocinolone pf otic solution 1 or 1b* QL neomycin-polymyxin-hc otic solution 1 or 1b* neomycin-polymyxin-hc otic suspension 1 or 1b* QL *OTIC STEROIDS*** fluocinolone acetonide otic oil 1 or 1b* hydrocortisone-acetic acid otic solution 1 or 1b* QL *OXYTOCICS* *ABORTIFACIENTS/CER VICAL RIPENING - PROSTAGLANDINS*** carboprost tromethamine intramuscular solution 1 or 1b* *OXYTOCICS*** methergine oral tablet 1 or 1b* methylergonovine maleate injection solution 1 or 1b* methylergonovine maleate oral tablet 1 or 1b* oxytocin injection solution 1 or 1b* *PASSIVE IMMUNIZING AND TREATMENT AGENTS* *ANTITOXINS- ANTIVENINS*** ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED 2 ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 2 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION RECONSTITUTED 2 CROFAB INTRAVENOUS SOLUTION RECONSTITUTED 2 Drug Name Tier Notes *IMMUNE SERUMS*** CUTAQUIG SUBCUTANEOUS SOLUTION 4 PA; LD; SP GAMUNEX-C INJECTION SOLUTION 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML 4 PA; LD; SP XEMBIFY SUBCUTANEOUS SOLUTION 4 PA; LD; SP *PENICILLINS* *AMINOPENICILLINS** * amoxicillin oral capsule 1 or 1a* amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml 1 or 1a* amoxicillin oral tablet 1 or 1a* amoxicillin oral tablet chewable 125 mg, 250 mg 1 or 1a* ampicillin oral capsule 500 mg 1 or 1a* ampicillin sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg 2 ampicillin sodium intravenous solution reconstituted 2 *NATURAL PENICILLINS*** penicillin g potassium injection solution reconstituted 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 80