Drug Name Tier Notes LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP MVASI INTRAVENOUS SOLUTION 4 PA; LD; SP *ANTIPARKINSON AND RELATED THERAPY AGENTS* *ANTIPARKINSON ANTICHOLINERGICS*** benztropine mesylate injection solution 1 or 1a* benztropine mesylate oral tablet 1 or 1a* trihexyphenidyl hcl oral solution 1 or 1a* trihexyphenidyl hcl oral tablet 1 or 1a* *ANTIPARKINSON DOPAMINERGICS*** amantadine hcl oral capsule 1 or 1b* QL amantadine hcl oral solution 1 or 1b* QL amantadine hcl oral tablet 1 or 1b* QL bromocriptine mesylate oral capsule 1 or 1b* bromocriptine mesylate oral tablet 1 or 1b* *ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS*** rasagiline mesylate oral tablet 2 QL selegiline hcl oral capsule 2 selegiline hcl oral tablet 2 *CENTRAL/PERIPHERA L COMT INHIBITORS*** tolcapone oral tablet 2 PA; QL *DECARBOXYLASE INHIBITORS*** carbidopa oral tablet 2 Drug Name Tier Notes *LEVODOPA COMBINATIONS*** carbidopa-levodopa er oral tablet extended release 25- 100 mg, 50-200 mg 2 carbidopa-levodopa oral tablet 1 or 1b* carbidopa-levodopa oral tablet dispersible 2 carbidopa-levodopa- entacapone oral tablet 12.5- 50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25- 125-200 mg, 37.5-150-200 mg, 50-200-200 mg 2 *NONERGOLINE DOPAMINE RECEPTOR AGONISTS*** apomorphine hcl subcutaneous solution cartridge 4 PA; LD; QL; SP pramipexole dihydrochloride er oral tablet extended release 24 hour 1 or 1b* QL pramipexole dihydrochloride oral tablet 1 or 1b* QL ropinirole hcl er oral tablet extended release 24 hour 1 or 1b* ropinirole hcl oral tablet 1 or 1b* *PERIPHERAL COMT INHIBITORS*** entacapone oral tablet 2 QL *ANTIPSYCHOTICS/ANT IMANIC AGENTS* *ANTIMANIC AGENTS*** lithium carbonate er oral tablet extended release 1 or 1a* QL lithium carbonate oral capsule 1 or 1a* QL lithium carbonate oral tablet 1 or 1a* QL lithium oral solution 1 or 1b* *ANTIPSYCHOTICS - MISC.*** CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG 3 ST; DO CAPLYTA ORAL CAPSULE 42 MG 3 ST; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 34