Drug Name Tier Notes curity sterile saline irrigation solution 2 glycine irrigation solution 1 or 1b* glycine urologic irrigation solution 1 or 1b* sodium chloride irrigation solution 0.9 % 2 *PROSTATIC HYPERTROPHY AGENT COMBINATIONS*** dutasteride-tamsulosin hcl oral capsule 1 or 1b* QL *URINARY STONE AGENTS*** tiopronin oral tablet 2 PA; LD; QL tiopronin oral tablet delayed release 2 PA; LD; QL VENXXIVA ORAL TABLET DELAYED RELEASE 2 PA; LD; QL *GOUT AGENTS* *GOUT AGENT COMBINATIONS*** colchicine-probenecid oral tablet 1 or 1b* *GOUT AGENTS*** allopurinol oral tablet 100 mg, 300 mg 1 or 1a* QL allopurinol sodium intravenous solution reconstituted 1 or 1b* colchicine oral tablet 2 QL febuxostat oral tablet 2 ST; QL *URICOSURICS*** probenecid oral tablet 1 or 1b* *HEMATOLOGICAL AGENTS - MISC.* *BRADYKININ B2 RECEPTOR ANTAGONISTS*** icatibant acetate subcutaneous solution prefilled syringe 4 PA; LD; QL; SP sajazir subcutaneous solution prefilled syringe 4 PA; LD; QL *C1 ESTERASE INHIBITORS*** BERINERT INTRAVENOUS KIT 4 PA; LD; QL; SP Drug Name Tier Notes HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP *DIRECT-ACTING P2Y12 INHIBITORS*** BRILINTA ORAL TABLET 2 QL ticagrelor oral tablet 1 or 1b* QL *GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS*** eptifibatide intravenous solution 20 mg/10ml, 200 mg/100ml, 75 mg/100ml 2 tirofiban hcl in nacl intravenous solution 2 *HEMATORHEOLOGIC AGENTS*** pentoxifylline er oral tablet extended release 1 or 1b* *PHOSPHODIESTERASE III INHIBITORS*** cilostazol oral tablet 2 *PLASMA EXPANDERS*** hetastarch-nacl intravenous solution 1 or 1b* lmd in d5w intravenous solution 1 or 1b* lmd in nacl intravenous solution 1 or 1b* *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** TAKHZYRO SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP TAKHZYRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 57