Drug Name Tier Notes IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG 2 PA; LD; QL *ANTINEOPLASTIC - EGFR INHIBITORS*** erlotinib hcl oral tablet 1 or 1b* PA; LD; QL; SP gefitinib oral tablet 4 PA; LD; QL; SP GILOTRIF ORAL TABLET 4 PA; LD; QL *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** ERIVEDGE ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** ZOLINZA ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - IMMUNOMODULATORS *** POMALYST ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - MEK INHIBITORS*** MEKINIST ORAL TABLET 4 PA; LD; QL; SP *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 4 PA; LD; SP everolimus oral tablet soluble 4 PA; LD; SP TORPENZ ORAL TABLET 4 PA; LD; SP *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** CABOMETYX ORAL TABLET 2 PA; LD; QL; SP CAPRELSA ORAL TABLET 4 PA; LD; QL COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 MG 4 PA; LD; QL; SP COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 MG & 80 MG 4 PA; LD; QL; SP Drug Name Tier Notes COMETRIQ (60 MG DAILY DOSE) ORAL KIT 4 PA; LD; QL; SP lapatinib ditosylate oral tablet 4 PA; LD; QL; SP pazopanib hcl oral tablet 4 PA; LD; QL; SP sorafenib tosylate oral tablet 4 PA; LD; QL; SP STIVARGA ORAL TABLET 4 PA; LD; QL; SP sunitinib malate oral capsule 4 PA; LD; QL; SP *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** VITRAKVI ORAL CAPSULE 4 PA; LD; QL; SP VITRAKVI ORAL SOLUTION 4 PA; LD; QL; SP *ANTINEOPLASTIC COMBINATIONS*** HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 4 LD; SP *ANTINEOPLASTICS MISC.*** ACTIMMUNE SUBCUTANEOUS SOLUTION 4 PA; LD; SP hydroxyurea oral capsule 2 LD MATULANE ORAL CAPSULE 4 LD *AROMATASE INHIBITORS*** anastrozole oral tablet 2 LD; $0 exemestane oral tablet 2 LD; $0 letrozole oral tablet 2 LD; $0 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** IBRANCE ORAL CAPSULE 4 PA; LD; QL; SP IBRANCE ORAL TABLET 4 PA; LD; QL; SP KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP KISQALI (400 MG DOSE) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 32