Drug Name Tier Notes fluvoxamine maleate oral tablet 1 or 1b* paroxetine hcl er oral tablet extended release 24 hour 1 or 1b* paroxetine hcl oral suspension 2 paroxetine hcl oral tablet 1 or 1b* sertraline hcl oral concentrate 1 or 1b* sertraline hcl oral tablet 1 or 1b* *SEROTONIN MODULATORS*** nefazodone hcl oral tablet 100 mg, 50 mg 1 or 1b* DO nefazodone hcl oral tablet 150 mg, 200 mg, 250 mg 1 or 1b* QL trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1 or 1a* DO trazodone hcl oral tablet 300 mg 1 or 1a* QL TRINTELLIX ORAL TABLET 10 MG, 5 MG 3 DO TRINTELLIX ORAL TABLET 20 MG 3 QL vilazodone hcl oral tablet 10 mg, 20 mg 1 or 1b* DO vilazodone hcl oral tablet 40 mg 1 or 1b* QL *SEROTONIN- NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg 1 or 1b* QL desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg 1 or 1b* DO duloxetine hcl oral capsule delayed release particles 2 QL venlafaxine hcl er oral capsule extended release 24 hour 1 or 1b* QL venlafaxine hcl er oral tablet extended release 24 hour 225 mg 1 or 1b* QL venlafaxine hcl oral tablet 1 or 1b* QL Drug Name Tier Notes *TRICYCLIC AGENTS*** amitriptyline hcl oral tablet 10 mg, 25 mg, 50 mg, 75 mg 1 or 1a* DO amitriptyline hcl oral tablet 100 mg, 150 mg 1 or 1a* QL amoxapine oral tablet 100 mg, 150 mg 1 or 1b* QL amoxapine oral tablet 25 mg, 50 mg 1 or 1b* DO clomipramine hcl oral capsule 25 mg 1 or 1b* DO clomipramine hcl oral capsule 50 mg, 75 mg 1 or 1b* QL desipramine hcl oral tablet 10 mg, 25 mg, 50 mg, 75 mg 2 DO desipramine hcl oral tablet 100 mg, 150 mg 2 QL doxepin hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 or 1b* DO doxepin hcl oral capsule 100 mg, 150 mg 1 or 1b* QL doxepin hcl oral concentrate 1 or 1b* QL imipramine hcl oral tablet 10 mg, 25 mg 1 or 1b* DO imipramine hcl oral tablet 50 mg 1 or 1b* QL imipramine pamoate oral capsule 100 mg, 75 mg 1 or 1b* DO imipramine pamoate oral capsule 125 mg, 150 mg 1 or 1b* QL nortriptyline hcl oral capsule 10 mg, 25 mg 1 or 1b* DO nortriptyline hcl oral capsule 50 mg, 75 mg 1 or 1b* QL nortriptyline hcl oral solution 1 or 1b* QL protriptyline hcl oral tablet 10 mg 2 QL protriptyline hcl oral tablet 5 mg 2 DO trimipramine maleate oral capsule 1 or 1b* QL *ANTIDIABETICS* *ALPHA-GLUCOSIDASE INHIBITORS*** acarbose oral tablet 1 or 1b* QL miglitol oral tablet 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 21