Drug Name Tier Notes sb bisacodyl laxative ec oral tablet delayed release 1 or 1a* $0 sb gentle lax-women oral tablet delayed release 1 or 1a* $0 womans laxative oral tablet delayed release 1 or 1a* $0 womens laxative oral tablet delayed release 1 or 1a* $0 *LOCAL ANESTHETICS- PARENTERAL* *LOCAL ANESTHETIC & SYMPATHOMIMETIC** * bupivacaine-epinephrine (pf) injection solution 0.25% - 1:200000, 0.5% -1:200000 1 or 1b* lidocaine-epinephrine (pf) injection solution 1.5 %- 1:200000, 2 %-1:200000 1 or 1b* lidocaine-epinephrine injection solution 0.5 %- 1:200000, 2 %-1:100000 1 or 1b* sensorcaine/epinephrine injection solution 1 or 1b* sensorcaine-mpf/epinephrine injection solution 0.25% - 1:200000 1 or 1b* *LOCAL ANESTHETICS - AMIDES*** bupivacaine hcl (pf) injection solution 1 or 1b* lidocaine hcl (pf) injection solution 1 or 1b* lidocaine hcl injection solution 0.5 % 1 or 1b* polocaine injection solution 1 or 1b* polocaine-mpf injection solution 1 or 1b* ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 mg/ml 1 or 1b* ROPIVACAINE HCL INJECTION SOLUTION 2 MG/ML 1 or 1b* sensorcaine injection solution 1 or 1b* sensorcaine-mpf injection solution 1 or 1b* Drug Name Tier Notes *LOCAL ANESTHETICS - ESTERS*** chloroprocaine hcl (pf) injection solution 1 or 1b* *MACROLIDES* *AZITHROMYCIN*** azithromycin intravenous solution reconstituted 500 mg 2 azithromycin oral suspension reconstituted 1 or 1b* azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 or 1b* *CLARITHROMYCIN*** clarithromycin er oral tablet extended release 24 hour 1 or 1b* clarithromycin oral suspension reconstituted 1 or 1b* clarithromycin oral tablet 1 or 1b* *ERYTHROMYCINS*** e.e.s. 400 oral tablet 1 or 1b* erythromycin base oral capsule delayed release particles 1 or 1b* erythromycin base oral tablet 1 or 1b* erythromycin base oral tablet delayed release 1 or 1b* erythromycin ethylsuccinate oral suspension reconstituted 2 erythromycin lactobionate intravenous solution reconstituted 2 erythromycin oral tablet delayed release 1 or 1b* *MEDICAL DEVICES AND SUPPLIES* *CERVICAL CAPS*** FEMCAP VAGINAL DEVICE 2 $0 *CONDOMS - FEMALE*** FC2 FEMALE CONDOM 2 $0; QL *DIAPHRAGMS*** CAYA VAGINAL DIAPHRAGM 2 $0 WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 62