Drug Name Tier Notes lurasidone hcl oral tablet 120 mg 2 AL lurasidone hcl oral tablet 20 mg, 40 mg 2 DO; AL lurasidone hcl oral tablet 60 mg, 80 mg 2 AL; QL VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG 2 ST; DO VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG 2 ST; QL ziprasidone hcl oral capsule 20 mg, 40 mg 2 DO; AL ziprasidone hcl oral capsule 60 mg, 80 mg 2 AL; QL ziprasidone mesylate intramuscular solution reconstituted 2 AL; QL *BENZISOXAZOLES*** paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg 2 DO paliperidone er oral tablet extended release 24 hour 6 mg, 9 mg 2 QL risperidone microspheres er intramuscular suspension reconstituted er 2 AL; QL risperidone oral solution 1 or 1b* AL; QL risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* DO; AL risperidone oral tablet 3 mg, 4 mg 1 or 1b* AL; QL risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 2 DO; AL risperidone oral tablet dispersible 3 mg, 4 mg 2 AL; QL *BUTYROPHENONES*** haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml 1 or 1b* AL; QL haloperidol lactate injection solution 5 mg/ml 1 or 1b* AL haloperidol lactate oral concentrate 2 mg/ml 1 or 1b* AL; QL haloperidol oral tablet 0.5 mg, 1 mg, 2 mg 1 or 1b* DO; AL haloperidol oral tablet 10 mg, 20 mg, 5 mg 1 or 1b* AL; QL Drug Name Tier Notes *DIBENZODIAZEPINES* ** clozapine oral tablet 100 mg, 200 mg 2 AL; QL clozapine oral tablet 25 mg, 50 mg 2 DO; AL clozapine oral tablet dispersible 100 mg, 150 mg, 200 mg 2 AL; QL clozapine oral tablet dispersible 12.5 mg, 25 mg 2 DO; AL *DIBENZO-OXEPINO PYRROLES*** asenapine maleate sublingual tablet sublingual 10 mg 2 AL; QL asenapine maleate sublingual tablet sublingual 2.5 mg, 5 mg 2 DO; AL *DIBENZOTHIAZEPINE S*** quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg 2 DO; AL quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg, 50 mg 2 AL; QL quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 or 1b* DO; AL quetiapine fumarate oral tablet 150 mg, 300 mg, 400 mg 1 or 1b* AL; QL *DIBENZOXAZEPINES** * loxapine succinate oral capsule 10 mg, 25 mg, 5 mg 1 or 1b* DO; AL loxapine succinate oral capsule 50 mg 1 or 1b* AL; QL *DIHYDROINDOLONES* ** molindone hcl oral tablet 10 mg, 5 mg 2 DO; AL molindone hcl oral tablet 25 mg 2 AL; QL *PHENOTHIAZINES*** chlorpromazine hcl injection solution 1 or 1b* AL CHLORPROMAZINE HCL ORAL CONCENTRATE 1 or 1b* AL; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 35