Drug Name Tier Notes *AMINOGLYCOSIDES* *AMINOGLYCOSIDES** * amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml 2 gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-% 2 gentamicin sulfate injection solution 2 neomycin sulfate oral tablet 1 or 1a* streptomycin sulfate intramuscular solution reconstituted 1 or 1b* tobramycin inhalation nebulization solution 4 LD; QL; SP tobramycin sulfate injection solution 2 QL tobramycin sulfate injection solution reconstituted 2 QL *ANALGESICS - ANTI- INFLAMMATORY* *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** RINVOQ LQ ORAL SOLUTION 4 PA; LD; QL; SP RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; LD; QL; SP XELJANZ ORAL SOLUTION 4 PA; LD; QL; SP XELJANZ ORAL TABLET 4 PA; LD; QL; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; LD; QL; SP Drug Name Tier Notes *ANTIRHEUMATIC ANTIMETABOLITES*** RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML 4 PA; LD; QL; SP *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** HUMIRA (2 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 4 PA; LD; QL; SP HUMIRA (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML 4 PA; LD; QL; SP HUMIRA-CD/UC/HS STARTER SUBCUTANEOUS AUTO- INJECTOR KIT 80 MG/0.8ML 4 PA; LD; QL; SP HUMIRA- PSORIASIS/UVEIT STARTER SUBCUTANEOUS AUTO- INJECTOR KIT 4 PA; LD; QL; SP SIMLANDI (1 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 40 MG/0.4ML 4 PA; LD; QL; SP SIMLANDI (1 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 80 MG/0.8ML 4 PA; QL; SP SIMLANDI (1 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; QL; SP SIMLANDI (2 PEN) SUBCUTANEOUS AUTO- INJECTOR KIT 4 PA; LD; QL; SP SIMLANDI (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.2ML 4 PA; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 9