Drug Name Tier Notes *GLYCOPEPTIDES*** vancomycin hcl intravenous solution reconstituted 100 gm 2 QL vancomycin hcl oral capsule 2 QL vancomycin hcl oral solution reconstituted 25 mg/ml, 50 mg/ml 2 QL VANCOMYCIN HCL ORAL SOLUTION RECONSTITUTED 250 MG/5ML 2 QL *LEPROSTATICS*** dapsone oral tablet 2 *LINCOSAMIDES*** clindamycin hcl oral capsule 1 or 1b* clindamycin palmitate hcl oral solution reconstituted 1 or 1b* clindamycin phosphate in d5w intravenous solution 1 or 1b* clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml 1 or 1b* *MONOBACTAMS*** aztreonam injection solution reconstituted 2 *OXAZOLIDINONES*** linezolid intravenous solution 600 mg/300ml 1 or 1b* linezolid oral suspension reconstituted 1 or 1b* PA; QL linezolid oral tablet 1 or 1b* PA; QL *POLYMYXINS*** colistimethate sodium (cba) injection solution reconstituted 2 polymyxin b sulfate injection solution reconstituted 2 *URINARY ANTI- INFECTIVES*** fosfomycin tromethamine oral packet 1 or 1b* methenamine hippurate oral tablet 2 nitrofurantoin macrocrystal oral capsule 1 or 1b* nitrofurantoin monohyd macro oral capsule 1 or 1b* Drug Name Tier Notes nitrofurantoin oral suspension 25 mg/5ml, 50 mg/10ml 1 or 1b* *ANTIMALARIALS* *ANTIMALARIAL COMBINATIONS*** atovaquone-proguanil hcl oral tablet 1 or 1b* *ANTIMALARIALS*** chloroquine phosphate oral tablet 1 or 1a* HYDROXYCHLOROQUI NE SULFATE ORAL TABLET 100 MG, 300 MG, 400 MG 1 or 1b* QL hydroxychloroquine sulfate oral tablet 200 mg 1 or 1b* QL mefloquine hcl oral tablet 1 or 1b* QL pyrimethamine oral tablet 1 or 1b* PA; QL quinine sulfate oral capsule 1 or 1b* PA; QL *ANTIMYASTHENIC/CH OLINERGIC AGENTS* *ANTIMYASTHENIC/CH OLINERGIC AGENTS*** pyridostigmine bromide er oral tablet extended release 2 pyridostigmine bromide oral solution 2 pyridostigmine bromide oral tablet 2 *ANTIMYCOBACTERIA L AGENTS* *ANTIMYCOBACTERIA L AGENTS*** cycloserine oral capsule 1 or 1b* ethambutol hcl oral tablet 2 isoniazid injection solution 1 or 1a* isoniazid oral syrup 1 or 1a* isoniazid oral tablet 1 or 1a* PRIFTIN ORAL TABLET 2 pyrazinamide oral tablet 2 rifabutin oral capsule 2 rifampin intravenous solution reconstituted 2 rifampin oral capsule 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 30