Drug Name Tier Notes *GRANULOCYTE COLONY- STIMULATING FACTORS (G-CSF)*** NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; LD; QL; SP NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP UDENYCA ONBODY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP UDENYCA SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 4 PA; LD; SP *IRON*** FERAHEME INTRAVENOUS SOLUTION 4 PA; LD; QL; SP FERRLECIT INTRAVENOUS SOLUTION 4 PA; LD; QL; SP ferumoxytol intravenous solution 4 PA; LD; QL; SP INFED INJECTION SOLUTION 4 PA; LD; SP na ferric gluc cplx in sucrose intravenous solution 4 PA; LD; QL; SP VENOFER INTRAVENOUS SOLUTION 4 PA; LD; QL; SP *THROMBOPOIETIN (TPO) RECEPTOR AGONISTS*** eltrombopag olamine oral packet 12.5 mg 4 PA; LD; DO; SP eltrombopag olamine oral packet 25 mg 4 PA; LD; QL; SP eltrombopag olamine oral tablet 12.5 mg, 25 mg 4 PA; LD; DO; SP Drug Name Tier Notes eltrombopag olamine oral tablet 50 mg, 75 mg 4 PA; LD; QL; SP *HEMOSTATICS* *HEMOSTATICS - SYSTEMIC*** aminocaproic acid intravenous solution 1 or 1b* aminocaproic acid oral solution 2 QL aminocaproic acid oral tablet 1000 mg 2 aminocaproic acid oral tablet 500 mg 2 QL tranexamic acid intravenous solution 1000 mg/10ml 2 tranexamic acid oral tablet 1 or 1b* QL *HYPNOTICS/SEDATIVE S/SLEEP DISORDER AGENTS* *BARBITURATE HYPNOTICS*** pentobarbital sodium injection solution 1 or 1b* phenobarbital oral elixir 1 or 1b* QL phenobarbital oral tablet 100 mg, 60 mg, 64.8 mg, 97.2 mg 1 or 1b* QL phenobarbital oral tablet 15 mg, 16.2 mg, 30 mg, 32.4 mg 1 or 1b* DO phenobarbital sodium injection solution 1 or 1b* *BENZODIAZEPINE HYPNOTICS*** estazolam oral tablet 1 or 1b* QL flurazepam hcl oral capsule 1 or 1b* QL midazolam hcl (pf) +rfid injection solution 1 or 1b* midazolam hcl (pf) injection solution 1 or 1b* midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 25 mg/5ml, 5 mg/ml, 50 mg/10ml 1 or 1b* midazolam hcl oral syrup 1 or 1b* QL midazolam-sodium chloride (pf) intravenous solution 100-0.9 mg/100ml-%, 50-0.9 mg/50ml-% 1 or 1b* quazepam oral tablet 1 or 1b* QL temazepam oral capsule 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 59