Drug Name Tier Notes nitroglycerin translingual solution 2 *ANTIANXIETY AGENTS* *ANTIANXIETY AGENTS - MISC.*** buspirone hcl oral tablet 1 or 1b* droperidol injection solution 1 or 1b* hydroxyzine hcl intramuscular solution 1 or 1b* hydroxyzine hcl oral syrup 1 or 1b* hydroxyzine hcl oral tablet 1 or 1b* hydroxyzine pamoate oral capsule 1 or 1a* meprobamate oral tablet 3 *BENZODIAZEPINES*** alprazolam er oral tablet extended release 24 hour 1 or 1b* QL alprazolam oral tablet 1 or 1b* QL alprazolam oral tablet dispersible 1 or 1b* QL alprazolam xr oral tablet extended release 24 hour 1 or 1b* QL chlordiazepoxide hcl oral capsule 1 or 1b* QL clorazepate dipotassium oral tablet 1 or 1b* QL diazepam injection solution 10 mg/2ml 1 or 1a* diazepam intensol oral concentrate 1 or 1a* QL diazepam oral concentrate 1 or 1a* QL diazepam oral solution 5 mg/5ml 1 or 1a* diazepam oral tablet 1 or 1a* QL lorazepam injection solution 1 or 1b* lorazepam intensol oral concentrate 1 or 1b* QL lorazepam oral concentrate 2 mg/ml 1 or 1b* QL lorazepam oral tablet 1 or 1b* QL oxazepam oral capsule 2 QL Drug Name Tier Notes *ANTIARRHYTHMICS* *ANTIARRHYTHMICS - MISC.*** adenosine intravenous solution 12 mg/4ml, 6 mg/2ml 1 or 1b* *ANTIARRHYTHMICS TYPE I-A*** disopyramide phosphate oral capsule 2 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 procainamide hcl injection solution 2 quinidine gluconate er oral tablet extended release 2 quinidine sulfate oral tablet 1 or 1a* *ANTIARRHYTHMICS TYPE I-B*** lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml 1 or 1b* lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 1 or 1b* lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-% 1 or 1b* mexiletine hcl oral capsule 2 *ANTIARRHYTHMICS TYPE I-C*** flecainide acetate oral tablet 2 QL propafenone hcl er oral capsule extended release 12 hour 2 propafenone hcl oral tablet 2 *ANTIARRHYTHMICS TYPE III*** amiodarone hcl intravenous solution 1 or 1b* amiodarone hcl oral tablet 100 mg, 400 mg 1 or 1b* amiodarone hcl oral tablet 200 mg 1 or 1b* QL dofetilide oral capsule 4 LD ibutilide fumarate intravenous solution 1 or 1b* pacerone oral tablet 100 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 15