Drug Name Tier Notes *OPHTHALMIC STEROID COMBINATIONS*** bacitra-neomycin- polymyxin-hc ophthalmic ointment 1 or 1b* QL neomycin-polymyxin- dexameth ophthalmic ointment 1 or 1a* QL neomycin-polymyxin- dexameth ophthalmic suspension 1 or 1a* QL neomycin-polymyxin-hc ophthalmic suspension 3.5- 10000-1 1 or 1b* neo-polycin hc ophthalmic ointment 1 or 1b* QL sulfacetamide-prednisolone ophthalmic solution 1 or 1a* QL TOBRADEX OPHTHALMIC OINTMENT 2 tobramycin-dexamethasone ophthalmic suspension 1 or 1b* QL ZYLET OPHTHALMIC SUSPENSION 2 QL *OPHTHALMIC STEROIDS*** dexamethasone sodium phosphate ophthalmic solution 1 or 1b* difluprednate ophthalmic emulsion 1 or 1b* QL fluorometholone ophthalmic suspension 1 or 1b* LOTEMAX OPHTHALMIC OINTMENT 3 QL loteprednol etabonate ophthalmic gel 1 or 1b* QL loteprednol etabonate ophthalmic suspension 0.5 % 1 or 1b* QL prednisolone acetate ophthalmic suspension 1 or 1b* QL *OPHTHALMIC SULFONAMIDES*** sulfacetamide sodium ophthalmic ointment 1 or 1b* QL sulfacetamide sodium ophthalmic solution 1 or 1b* QL Drug Name Tier Notes *OPHTHALMICS - CYSTINOSIS AGENTS** CYSTARAN OPHTHALMIC SOLUTION 4 PA; LD; QL *PROSTAGLANDINS - OPHTHALMIC*** bimatoprost ophthalmic solution 2 latanoprost ophthalmic solution 1 or 1b* QL LUMIGAN OPHTHALMIC SOLUTION 0.01 % 2 QL tafluprost (pf) ophthalmic solution 2 QL travoprost (bak free) ophthalmic solution 1 or 1b* QL *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS*** BYOOVIZ INTRAVITREAL SOLUTION 4 PA; LD; SP CIMERLI INTRAVITREAL SOLUTION 4 PA; LD; SP EYLEA HD INTRAVITREAL SOLUTION 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP *OTIC AGENTS* *OTIC AGENTS - MISCELLANEOUS*** acetic acid otic solution 1 or 1b* *OTIC ANTI- INFECTIVES*** ciprofloxacin hcl otic solution 1 or 1b* QL ofloxacin otic solution 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 79