Drug Name Tier Notes colesevelam hcl oral packet 3 QL colesevelam hcl oral tablet 2 QL colestipol hcl oral granules 1 or 1b* QL colestipol hcl oral packet 1 or 1b* QL colestipol hcl oral tablet 1 or 1b* QL prevalite oral packet 2 QL prevalite oral powder 2 QL *FIBRIC ACID DERIVATIVES*** fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg 1 or 1b* QL fenofibrate oral capsule 1 or 1b* QL fenofibrate oral tablet 120 mg, 40 mg 3 ST; QL fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 1 or 1b* QL fenofibric acid oral capsule delayed release 1 or 1b* QL fenofibric acid oral tablet 1 or 1b* QL gemfibrozil oral tablet 1 or 1b* QL *HMG COA REDUCTASE INHIBITORS*** atorvastatin calcium oral tablet 10 mg, 20 mg 1 or 1b* DO; $0 atorvastatin calcium oral tablet 40 mg 1 or 1b* DO atorvastatin calcium oral tablet 80 mg 1 or 1b* QL fluvastatin sodium oral capsule 1 or 1b* DO; $0 lovastatin oral tablet 10 mg, 20 mg 1 or 1b* DO; $0 lovastatin oral tablet 40 mg 1 or 1b* $0; QL pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg 1 or 1b* DO; $0 pravastatin sodium oral tablet 80 mg 1 or 1b* $0; QL rosuvastatin calcium oral tablet 10 mg, 5 mg 2 DO; $0 rosuvastatin calcium oral tablet 20 mg 2 DO rosuvastatin calcium oral tablet 40 mg 2 QL simvastatin oral tablet 10 mg, 20 mg, 5 mg 1 or 1b* DO; $0 simvastatin oral tablet 40 mg 1 or 1b* $0; QL Drug Name Tier Notes simvastatin oral tablet 80 mg 1 or 1b* PA; QL *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** ezetimibe-simvastatin oral tablet 2 ST; QL *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** ezetimibe oral tablet 2 QL *NICOTINIC ACID DERIVATIVES*** niacin (antihyperlipidemic) oral tablet 1 or 1b* ST; QL niacin er (antihyperlipidemic) oral tablet extended release 1 or 1b* ST; QL niacor oral tablet 1 or 1b* ST; QL *PCSK9 INHIBITORS*** REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 3 PA; QL REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA; QL *ANTIHYPERTENSIVES * *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** amlodipine besy-benazepril hcl oral capsule 1 or 1b* QL trandolapril-verapamil hcl er oral tablet extended release 1 or 1b* QL *ACE INHIBITORS & THIAZIDE/THIAZIDE- LIKE*** benazepril- hydrochlorothiazide oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 27