Drug Name Tier Notes permethrin external cream 1 or 1b* QL PRURADIK EXTERNAL LOTION 2 spinosad external suspension 1 or 1b* QL *STEROID-LOCAL ANESTHETIC COMBINATIONS*** PRAMOSONE EXTERNAL CREAM 1-1 % 2 PRAMOSONE EXTERNAL LOTION 2 *TAR PRODUCTS*** coal tar external solution 1 or 1b* *TOPICAL ANESTHETIC COMBINATIONS*** lidocaine-prilocaine external cream 2 QL lidocaine-prilocaine external kit 2 QL *TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS*** bexarotene external gel 4 PA; LD; QL; SP *TOPICAL STEROID COMBINATIONS*** calcipotriene-betameth diprop external ointment 3 ST; QL calcipotriene-betameth diprop external suspension 3 ST; QL *TYPE II 5-ALPHA REDUCTASE INHIBITORS*** finasteride oral tablet 1 mg 1 or 1b* *DIAGNOSTIC PRODUCTS* *DIAGNOSTIC TESTS*** ACCU-CHEK AVIVA PLUS IN VITRO STRIP 2 QL ACCU-CHEK GUIDE TEST IN VITRO STRIP 2 QL ACCU-CHEK SMARTVIEW IN VITRO STRIP 2 QL ACCUTREND GLUCOSE IN VITRO STRIP 2 QL FREESTYLE INSULINX TEST IN VITRO STRIP 2 QL Drug Name Tier Notes FREESTYLE LITE TEST IN VITRO STRIP 2 QL FREESTYLE PRECISION NEO TEST IN VITRO STRIP 2 QL FREESTYLE TEST IN VITRO STRIP 2 QL *DIGESTIVE AIDS* *DIGESTIVE ENZYMES*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL VIOKACE ORAL TABLET 3 QL ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000- 47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- 126000 UNIT, 5000-24000 UNIT, 60000-189600 UNIT 2 QL *DIURETICS* *CARBONIC ANHYDRASE INHIBITORS*** acetazolamide er oral capsule extended release 12 hour 1 or 1b* acetazolamide oral tablet 1 or 1b* acetazolamide sodium injection solution reconstituted 1 or 1b* dichlorphenamide oral tablet 4 PA; LD; QL methazolamide oral tablet 2 ORMALVI ORAL TABLET 4 PA; LD; QL *DIURETIC COMBINATIONS*** amiloride- hydrochlorothiazide oral tablet 1 or 1b* spironolactone-hctz oral tablet 1 or 1b* triamterene-hctz oral capsule 37.5-25 mg 1 or 1a* triamterene-hctz oral tablet 1 or 1a* *LOOP DIURETICS*** bumetanide injection solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 51