Four-Tier CURRENT AS OF 8/1/2025 Drug Name Tier Notes *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANT S* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** clonidine hcl er oral tablet extended release 12 hour 1 or 1b* PA guanfacine hcl er oral tablet extended release 24 hour 1 or 1b* PA *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule 1 or 1b* PA *AMPHETAMINE MIXTURES*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg 1 or 1b* PA; DO amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg 1 or 1b* PA; QL amphetamine- dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg 1 or 1b* PA; DO amphetamine- dextroamphetamine oral tablet 20 mg, 30 mg 1 or 1b* PA; QL amphet-dextroamphet 3-bead er oral capsule extended release 24 hour 2 PA; QL *AMPHETAMINES*** amphetamine sulfate oral tablet 10 mg 1 or 1b* QL amphetamine sulfate oral tablet 5 mg 1 or 1b* DO dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg 1 or 1b* PA; QL Drug Name Tier Notes dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg 1 or 1b* PA; DO dextroamphetamine sulfate oral solution 1 or 1b* PA; QL dextroamphetamine sulfate oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 7.5 mg 1 or 1b* PA; QL dextroamphetamine sulfate oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO lisdexamfetamine dimesylate oral capsule 10 mg, 20 mg, 30 mg 2 PA; DO lisdexamfetamine dimesylate oral capsule 40 mg, 50 mg, 60 mg, 70 mg 2 PA; QL lisdexamfetamine dimesylate oral tablet chewable 10 mg, 20 mg, 30 mg 2 PA; DO lisdexamfetamine dimesylate oral tablet chewable 40 mg, 50 mg, 60 mg 2 PA; QL procentra oral solution 1 or 1b* PA; QL zenzedi oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 7.5 mg 1 or 1b* PA; QL zenzedi oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO *ANALEPTICS*** caffeine citrate oral solution 2 *ANOREXIANTS NON- AMPHETAMINE*** benzphetamine hcl oral tablet 50 mg 1 or 1b* PA; BE; QL diethylpropion hcl er oral tablet extended release 24 hour 1 or 1b* PA; BE; QL diethylpropion hcl oral tablet 1 or 1b* PA; BE; QL phendimetrazine tartrate oral tablet 1 or 1b* PA; BE; QL phentermine hcl oral capsule 1 or 1b* PA; BE; QL phentermine hcl oral tablet 1 or 1b* PA; BE; QL *ANTI-OBESITY - GIP & GLP-1 RECEPTOR AGONISTS*** ZEPBOUND SUBCUTANEOUS SOLUTION AUTO- INJECTOR 2 PA; BE; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 7