Drug Name Tier Notes *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** DUPIXENT SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; SP DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML 4 PA; LD; SP *BURN PRODUCTS*** silver sulfadiazine external cream 1 or 1a* ssd external cream 1 or 1a* *CORTICOSTEROIDS - TOPICAL*** ala-cort external cream 1 % 1 or 1a* QL alclometasone dipropionate external cream 1 or 1b* QL alclometasone dipropionate external ointment 1 or 1b* QL betamethasone dipropionate aug external cream 1 or 1b* QL betamethasone dipropionate aug external gel 1 or 1b* QL betamethasone dipropionate aug external lotion 1 or 1b* QL betamethasone dipropionate aug external ointment 1 or 1b* QL betamethasone dipropionate external cream 1 or 1b* QL betamethasone dipropionate external lotion 1 or 1b* QL betamethasone dipropionate external ointment 1 or 1b* QL betamethasone valerate external cream 1 or 1b* QL betamethasone valerate external lotion 1 or 1b* QL betamethasone valerate external ointment 1 or 1b* QL clobetasol propionate e external cream 1 or 1b* QL clobetasol propionate emulsion external foam 1 or 1b* QL clobetasol propionate external cream 0.05 % 1 or 1b* QL Drug Name Tier Notes clobetasol propionate external foam 1 or 1b* QL clobetasol propionate external gel 1 or 1b* QL clobetasol propionate external liquid 1 or 1b* QL clobetasol propionate external lotion 1 or 1b* QL clobetasol propionate external ointment 1 or 1b* QL clobetasol propionate external shampoo 1 or 1b* QL clobetasol propionate external solution 1 or 1b* QL clodan external shampoo 1 or 1b* QL desonide external cream 1 or 1b* QL desonide external gel 1 or 1b* QL desonide external lotion 1 or 1b* QL desonide external ointment 1 or 1b* QL fluocinolone acetonide body external oil 1 or 1b* QL fluocinolone acetonide external cream 1 or 1b* QL fluocinolone acetonide external ointment 1 or 1b* QL fluocinolone acetonide external solution 1 or 1b* QL fluocinolone acetonide scalp external oil 1 or 1b* QL fluocinonide emulsified base external cream 1 or 1b* QL fluocinonide external cream 1 or 1b* QL fluocinonide external gel 1 or 1b* QL fluocinonide external ointment 1 or 1b* QL fluocinonide external solution 1 or 1b* QL fluticasone propionate external cream 1 or 1b* QL fluticasone propionate external lotion 1 or 1b* QL fluticasone propionate external ointment 1 or 1b* QL halobetasol propionate external cream 1 or 1b* QL halobetasol propionate external ointment 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 49