Drug Name Tier Notes buprenorphine hcl-naloxone hcl sublingual tablet sublingual 1 or 1b* QL buprenorphine transdermal patch weekly 2 PA; QL butorphanol tartrate injection solution 2 butorphanol tartrate nasal solution 1 or 1b* QL nalbuphine hcl injection solution 2 QL pentazocine-naloxone hcl oral tablet 1 or 1b* QL *TRAMADOL COMBINATIONS*** tramadol-acetaminophen oral tablet 1 or 1b* AL; QL *ANDROGENS- ANABOLIC* *ANDROGENS*** danazol oral capsule 2 QL DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 1 or 1b* PA testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml 1 or 1b* PA testosterone enanthate intramuscular solution 1 or 1b* PA testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) 2 PA; QL testosterone transdermal solution 2 PA; QL XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 3 PA *ANORECTAL AND RELATED PRODUCTS* *INTRARECTAL STEROIDS*** budesonide rectal foam 2 QL hydrocortisone rectal enema 1 or 1b* Drug Name Tier Notes *NITRATE VASODILATING AGENTS*** nitroglycerin rectal ointment 2 QL *RECTAL ANESTHETIC/STEROIDS *** hydrocortisone ace- pramoxine external cream 1- 1 % 1 or 1b* *RECTAL STEROIDS*** hydrocortisone (perianal) external cream 1 or 1b* PROCTOCORT EXTERNAL CREAM 1 or 1b* procto-med hc external cream 1 or 1b* proctosol hc external cream 1 or 1b* proctozone-hc external cream 1 or 1b* *ANTHELMINTICS* *ANTHELMINTICS*** albendazole oral tablet 1 or 1b* PA; QL ivermectin oral tablet 1 or 1b* QL praziquantel oral tablet 2 *ANTIANGINAL AGENTS* *ANTIANGINALS- OTHER*** ranolazine er oral tablet extended release 12 hour 2 QL *NITRATES*** isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1 or 1b* isosorbide dinitrate oral tablet 40 mg 2 isosorbide mononitrate er oral tablet extended release 24 hour 1 or 1b* NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR 2 nitroglycerin in d5w intravenous solution 1 or 1b* nitroglycerin sublingual tablet sublingual 1 or 1b* nitroglycerin transdermal patch 24 hour 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 14