Drug Name Tier Notes THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL theophylline er oral tablet extended release 12 hour 100 mg, 200 mg 1 or 1b* theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 or 1b* QL theophylline er oral tablet extended release 24 hour 1 or 1b* QL theophylline oral elixir 1 or 1b* QL theophylline oral solution 1 or 1b* QL *ANTICOAGULANTS* *COUMARIN ANTICOAGULANTS*** jantoven oral tablet 1 or 1a* warfarin sodium oral tablet 1 or 1a* *DIRECT FACTOR XA INHIBITORS*** ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 2 QL ELIQUIS ORAL TABLET 2 QL rivaroxaban oral tablet 2 QL XARELTO ORAL SUSPENSION RECONSTITUTED 2 QL XARELTO ORAL TABLET 2 QL XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 QL *HEPARINS AND HEPARINOID-LIKE AGENTS*** bd heparin posiflush intravenous solution 2 heparin (porcine) in nacl intravenous solution 1000- 0.9 ut/500ml-%, 2000-0.9 unit/l-% 2 heparin na (pork) lock flsh pf intravenous solution 2 heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% 2 Drug Name Tier Notes heparin sod (pork) lock flush intravenous solution 10 unit/ml, 100 unit/ml 2 heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml 2 heparin sodium (porcine) pf injection solution 1000 unit/ml, 5000 unit/0.5ml 2 *LOW MOLECULAR WEIGHT HEPARINS*** enoxaparin sodium injection solution 300 mg/3ml 1 or 1b* QL enoxaparin sodium injection solution prefilled syringe 1 or 1b* QL FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/4ML, 95000 UNIT/3.8ML 3 QL FRAGMIN SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL *SYNTHETIC HEPARINOID-LIKE AGENTS*** fondaparinux sodium subcutaneous solution 1 or 1b* QL *ANTICONVULSANTS* *AMPA GLUTAMATE RECEPTOR ANTAGONISTS*** perampanel oral tablet 2 *ANTICONVULSANTS - BENZODIAZEPINES*** clobazam oral suspension 2.5 mg/ml 2 QL clobazam oral tablet 2 QL clonazepam oral tablet 1 or 1b* QL clonazepam oral tablet dispersible 1 or 1b* QL diazepam rectal gel 1 or 1b* QL *ANTICONVULSANTS - MISC.*** carbamazepine er oral capsule extended release 12 hour 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 18