Drug Name Tier Notes hydrocortisone external cream 2.5 % 1 or 1a* QL hydrocortisone external lotion 2.5 % 1 or 1a* QL hydrocortisone external ointment 2.5 % 1 or 1a* QL mometasone furoate external cream 1 or 1b* QL mometasone furoate external ointment 1 or 1b* QL mometasone furoate external solution 1 or 1b* QL tovet external foam 1 or 1b* QL triamcinolone acetonide external cream 1 or 1a* QL triamcinolone acetonide external lotion 1 or 1a* QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % 1 or 1a* QL triderm external cream 0.5 % 1 or 1a* QL *IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL*** econazole nitrate external cream 1 or 1b* QL ketoconazole external cream 1 or 1b* QL ketoconazole external foam 3 QL ketoconazole external shampoo 2 % 1 or 1b* QL ketodan external foam 3 QL luliconazole external cream 1 or 1b* ST; QL oxiconazole nitrate external cream 3 ST; QL sulconazole nitrate external cream 1 or 1b* ST; QL sulconazole nitrate external solution 1 or 1b* ST; QL *IMMUNOMODULATOR S IMIDAZOQUINOLINAMI NES - TOPICAL*** imiquimod external cream 1 or 1b* QL imiquimod pump external cream 1 or 1b* ST; QL *KERATOLYTIC/ANTIM ITOTIC/VESICANT AGENTS*** podofilox external gel 2 QL Drug Name Tier Notes podofilox external solution 1 or 1b* QL *LOCAL ANESTHETICS - TOPICAL*** glydo external prefilled syringe 2 lidocaine external ointment 5 % 2 QL lidocaine external patch 5 % 2 PA; QL lidocaine hcl external solution 2 QL lidocaine hcl urethral/mucosal external gel 2 lidocaine hcl urethral/mucosal external prefilled syringe 2 TRIDACAINE II EXTERNAL PATCH 2 PA; QL TRIDACAINE III EXTERNAL PATCH 2 PA; QL *MACROLIDE IMMUNOSUPPRESSANT S - TOPICAL*** pimecrolimus external cream 1 or 1b* ST; QL tacrolimus external ointment 1 or 1b* ST; QL *OXABOROLE- RELATED ANTIFUNGALS - TOPICAL*** tavaborole external solution 2 ST; QL *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** EUCRISA EXTERNAL OINTMENT 3 ST; QL *ROSACEA AGENTS*** azelaic acid external gel 1 or 1b* QL brimonidine tartrate external gel 2 QL ivermectin external cream 2 QL metronidazole external cream 1 or 1b* QL metronidazole external gel 1 or 1b* QL metronidazole external lotion 1 or 1b* QL ZILXI EXTERNAL FOAM 2 QL *SCABICIDES & PEDICULICIDES*** crotan external lotion 2 QL malathion external lotion 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 50