Drug Name Tier Notes *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** mycophenolate mofetil oral capsule 4 LD mycophenolate mofetil oral suspension reconstituted 4 LD mycophenolate mofetil oral tablet 4 LD mycophenolate sodium oral tablet delayed release 4 LD mycophenolic acid oral tablet delayed release 180 mg, 360 mg 4 LD *IRRIGATION SOLUTIONS*** argyle sterile water irrigation solution 1 or 1b* lactated ringers irrigation solution 1 or 1b* physiolyte irrigation solution 1 or 1b* physiosol irrigation irrigation solution 1 or 1b* sterile water for irrigation irrigation solution 1 or 1b* water for irrigation, sterile irrigation solution 1 or 1b* *MACROLIDE IMMUNOSUPPRESSANT S*** everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg 4 LD sirolimus oral solution 4 LD sirolimus oral tablet 4 LD tacrolimus oral capsule 4 LD *POTASSIUM REMOVING AGENTS*** LOKELMA ORAL PACKET 3 QL sodium polystyrene sulfonate oral powder 2 sps (sodium polystyrene sulf) rectal suspension 2 *PURINE ANALOGS*** azasan oral tablet 1 or 1b* LD azathioprine oral tablet 1 or 1b* LD Drug Name Tier Notes *SCLEROSING AGENTS*** sodium tetradecyl sulfate intravenous solution 1 or 1b* SOTRADECOL INTRAVENOUS SOLUTION 1 % 1 or 1b* sotradecol intravenous solution 3 % 1 or 1b* *MOUTH/THROAT/DEN TAL AGENTS* *ANESTHETICS TOPICAL ORAL*** lidocaine hcl mouth/throat solution 1 or 1a* QL lidocaine viscous hcl mouth/throat solution 1 or 1a* QL *ANTI-INFECTIVES - THROAT*** clotrimazole mouth/throat troche 1 or 1b* QL *ANTISEPTICS - MOUTH/THROAT*** chlorhexidine gluconate mouth/throat solution 1 or 1a* QL periogard mouth/throat solution 1 or 1a* QL *DENTAL PRODUCTS - COMBINATIONS*** sodium fluoride 5000 enamel dental gel 1 or 1b* sodium fluoride 5000 sensitive dental gel 1 or 1b* *FLUORIDE DENTAL PRODUCTS*** clinpro 5000 dental paste 1 or 1b* QL denta 5000 plus dental cream 1 or 1b* QL dentagel dental gel 1 or 1a* QL fluoridex daily renewal mouth/throat concentrate 1 or 1b* fluoridex dental paste 1 or 1b* QL fluoridex enhanced whitening dental paste 1 or 1b* QL fluorimax 5000 dental paste 1 or 1b* fraiche 5000 dental dental gel 1 or 1b* QL just right 5000 dental paste 1 or 1b* sf 5000 plus dental cream 1 or 1b* QL sf dental gel 1 or 1a* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 72