Drug Name Tier Notes chlorpromazine hcl oral tablet 10 mg, 25 mg, 50 mg 1 or 1b* DO; AL chlorpromazine hcl oral tablet 100 mg, 200 mg 1 or 1b* AL; QL compro rectal suppository 1 or 1b* AL fluphenazine decanoate injection solution 1 or 1b* AL fluphenazine hcl injection solution 1 or 1b* AL fluphenazine hcl oral concentrate 1 or 1b* AL; QL fluphenazine hcl oral elixir 1 or 1b* AL; QL fluphenazine hcl oral tablet 1 mg, 2.5 mg, 5 mg 1 or 1b* DO; AL fluphenazine hcl oral tablet 10 mg 1 or 1b* AL; QL perphenazine oral tablet 16 mg, 4 mg, 8 mg 1 or 1b* AL; QL perphenazine oral tablet 2 mg 1 or 1b* DO; AL prochlorperazine edisylate injection solution 10 mg/2ml 1 or 1b* AL prochlorperazine maleate oral tablet 1 or 1a* AL prochlorperazine rectal suppository 1 or 1b* AL thioridazine hcl oral tablet 10 mg, 25 mg, 50 mg 1 or 1b* DO; AL thioridazine hcl oral tablet 100 mg 1 or 1b* AL; QL trifluoperazine hcl oral tablet 1 mg, 2 mg 1 or 1b* DO; AL trifluoperazine hcl oral tablet 10 mg, 5 mg 1 or 1b* AL; QL *QUINOLINONE DERIVATIVES*** aripiprazole oral solution 2 AL; QL aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg 2 DO; AL aripiprazole oral tablet 20 mg, 30 mg 2 AL; QL aripiprazole oral tablet dispersible 2 AL; QL REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 3 ST; DO REXULTI ORAL TABLET 3 MG, 4 MG 3 ST; QL Drug Name Tier Notes *THIENBENZODIAZEPI NES*** olanzapine intramuscular solution reconstituted 2 AL; QL olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 1 or 1b* DO; AL olanzapine oral tablet 15 mg, 20 mg 1 or 1b* AL; QL olanzapine oral tablet dispersible 10 mg, 5 mg 2 DO; AL olanzapine oral tablet dispersible 15 mg, 20 mg 2 AL; QL *THIOXANTHENES*** thiothixene oral capsule 1 mg, 2 mg, 5 mg 1 or 1b* PA; DO thiothixene oral capsule 10 mg 1 or 1b* PA; QL *ANTIVIRALS* *ANTIRETROVIRAL COMBINATIONS*** abacavir sulfate-lamivudine oral tablet 2 LD; QL BIKTARVY ORAL TABLET 4 LD; QL CIMDUO ORAL TABLET 4 LD; QL DESCOVY ORAL TABLET 120-15 MG 2 LD; QL DESCOVY ORAL TABLET 200-25 MG 2 LD; $0; QL DOVATO ORAL TABLET 4 LD; QL efavirenz-emtricitab-tenofo df oral tablet 4 LD; QL efavirenz-lamivudine- tenofovir oral tablet 4 LD; QL emtricitabine-tenofovir df oral tablet 100-150 mg, 133- 200 mg, 167-250 mg 1 or 1b* LD; QL emtricitabine-tenofovir df oral tablet 200-300 mg 1 or 1b* LD; $0; QL emtricitab-rilpivir-tenofov df oral tablet 1 or 1b* PA; LD; QL GENVOYA ORAL TABLET 4 LD; QL lamivudine-zidovudine oral tablet 2 LD; QL lopinavir-ritonavir oral tablet 4 LD; QL STRIBILD ORAL TABLET 4 LD; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 36