Drug Name Tier Notes levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml 2 QL levalbuterol tartrate inhalation aerosol 1 or 1b* ST; QL PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 2 QL SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT 2 QL terbutaline sulfate injection solution 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* *BRONCHODILATORS - ANTICHOLINERGICS*** ATROVENT HFA INHALATION AEROSOL SOLUTION 2 QL ipratropium bromide inhalation solution 1 or 1b* QL SPIRIVA HANDIHALER INHALATION CAPSULE 2 QL SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT 2 QL tiotropium bromide monohydrate inhalation capsule 2 QL *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP NUCALA SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP Drug Name Tier Notes NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *LEUKOTRIENE RECEPTOR ANTAGONISTS*** montelukast sodium oral packet 1 or 1b* QL montelukast sodium oral tablet 1 or 1b* QL montelukast sodium oral tablet chewable 1 or 1b* QL zafirlukast oral tablet 1 or 1b* QL *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** roflumilast oral tablet 2 QL *STEROID INHALANTS*** ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 2 QL budesonide inhalation suspension 1 or 1b* QL fluticasone propionate diskus inhalation aerosol powder breath activated 2 QL fluticasone propionate hfa inhalation aerosol 2 QL QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 QL *THYMIC STROMAL LYMPHOPOIETIN (TSLP) ANTAGONISTS*** TEZSPIRE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP TEZSPIRE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *XANTHINES*** aminophylline intravenous solution 1 or 1b* ELIXOPHYLLIN ORAL ELIXIR 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 17