Drug Name Tier Notes plenamine intravenous solution 1 or 1b* REFRESH AA 15 PKU ORAL LIQUID 2 REFRESH AA 15 TYR ORAL LIQUID 2 *CARBOHYDRATES*** dextrose intravenous solution 10 % 1 or 1b* *OPHTHALMIC AGENTS* *ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB*** SIMBRINZA OPHTHALMIC SUSPENSION 2 QL *BETA-BLOCKERS - OPHTHALMIC COMBINATIONS*** brimonidine tartrate-timolol ophthalmic solution 1 or 1b* QL dorzolamide hcl-timolol mal ophthalmic solution 1 or 1b* QL dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 or 1b* QL *BETA-BLOCKERS - OPHTHALMIC*** betaxolol hcl ophthalmic solution 1 or 1b* QL BETOPTIC-S OPHTHALMIC SUSPENSION 2 QL carteolol hcl ophthalmic solution 1 or 1a* levobunolol hcl ophthalmic solution 0.5 % 1 or 1b* timolol hemihydrate ophthalmic solution 2 QL timolol maleate (once-daily) ophthalmic solution 1 or 1b* QL timolol maleate ocudose ophthalmic solution 1 or 1b* QL timolol maleate ophthalmic gel forming solution 1 or 1b* QL timolol maleate ophthalmic solution 1 or 1b* QL Drug Name Tier Notes timolol maleate pf ophthalmic solution 1 or 1b* QL *CYCLOPLEGIC MYDRIATICS*** cyclopentolate hcl ophthalmic solution 1 % 1 or 1b* QL phenylephrine hcl ophthalmic solution 10 % 1 or 1b* tropicamide ophthalmic solution 1 or 1b* *LYMPHOCYTE FUNCTION- ASSOCIATED ANTIGEN- 1 (LFA-1) ANTAG*** XIIDRA OPHTHALMIC SOLUTION 2 PA; QL *MIOTICS - DIRECT ACTING*** pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 or 1b* *OPHTHALMIC - MULTIPLE RECEPTOR ANGIOGENESIS INHIBITORS*** VABYSMO INTRAVITREAL SOLUTION 4 PA; LD; SP VABYSMO INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP *OPHTHALMIC ANTIALLERGIC*** azelastine hcl ophthalmic solution 1 or 1b* QL cromolyn sodium ophthalmic solution 1 or 1a* QL epinastine hcl ophthalmic solution 1 or 1b* QL *OPHTHALMIC ANTIBIOTICS*** bacitracin ophthalmic ointment 1 or 1b* QL ciprofloxacin hcl ophthalmic solution 1 or 1a* QL gatifloxacin ophthalmic solution 1 or 1b* QL gentamicin sulfate ophthalmic solution 1 or 1a* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 77