Drug Name Tier Notes olmesartan-amlodipine-hctz oral tablet 1 or 1b* QL *ANTIADRENERGICS - CENTRALLY ACTING*** clonidine hcl oral tablet 1 or 1a* QL clonidine transdermal patch weekly 2 QL guanfacine hcl oral tablet 1 or 1b* methyldopa oral tablet 1 or 1b* QL *ANTIADRENERGICS - PERIPHERALLY ACTING*** doxazosin mesylate oral tablet 1 or 1b* QL prazosin hcl oral capsule 1 or 1b* terazosin hcl oral capsule 1 or 1b* QL *BETA BLOCKER & DIURETIC COMBINATIONS*** atenolol-chlorthalidone oral tablet 1 or 1b* QL bisoprolol- hydrochlorothiazide oral tablet 1 or 1b* QL metoprolol- hydrochlorothiazide oral tablet 1 or 1b* QL *DIRECT RENIN INHIBITORS*** aliskiren fumarate oral tablet 150 mg 2 DO aliskiren fumarate oral tablet 300 mg 2 QL *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** eplerenone oral tablet 2 *VASODILATORS*** hydralazine hcl injection solution 2 hydralazine hcl oral tablet 1 or 1b* minoxidil oral tablet 1 or 1b* Drug Name Tier Notes *ANTI-INFECTIVE AGENTS - MISC.* *ANTI-INFECTIVE AGENTS - MISC.*** metronidazole oral capsule 1 or 1a* metronidazole oral tablet 250 mg, 500 mg 1 or 1a* pentamidine isethionate inhalation solution reconstituted 2 LD pentamidine isethionate injection solution reconstituted 4 LD tinidazole oral tablet 1 or 1b* QL TRIMETHOPRIM ORAL TABLET 1 or 1a* XIFAXAN ORAL TABLET 3 PA; QL *ANTI-INFECTIVE MISC. - COMBINATIONS*** sulfamethoxazole- trimethoprim intravenous solution 2 sulfamethoxazole- trimethoprim oral suspension 1 or 1a* sulfamethoxazole- trimethoprim oral tablet 1 or 1a* sulfatrim pediatric oral suspension 1 or 1a* *ANTIPROTOZOAL AGENTS*** atovaquone oral suspension 2 nitazoxanide oral tablet 2 QL *CARBAPENEM COMBINATIONS*** imipenem-cilastatin intravenous solution reconstituted 2 *CARBAPENEMS*** meropenem intravenous solution reconstituted 1 gm, 500 mg 2 *CHLORAMPHENICALS *** chloramphenicol sod succinate intravenous solution reconstituted 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 29