Drug Name Tier Notes *PLASMA KALLIKREIN INHIBITORS*** KALBITOR SUBCUTANEOUS SOLUTION 4 PA; LD; QL; SP *PLATELET AGGREGATION INHIBITOR COMBINATIONS*** aspirin-dipyridamole er oral capsule extended release 12 hour 1 or 1b* QL *PLATELET AGGREGATION INHIBITORS*** dipyridamole oral tablet 2 *PROTAMINE*** protamine sulfate intravenous solution 1 or 1b* *QUINAZOLINE AGENTS*** anagrelide hcl oral capsule 1 or 1b* QL *THIENOPYRIDINE DERIVATIVES*** clopidogrel bisulfate oral tablet 1 or 1b* QL prasugrel hcl oral tablet 2 QL *HEMATOPOIETIC AGENTS* *AGENTS FOR GAUCHER DISEASE*** CERDELGA ORAL CAPSULE 2 PA; LD; QL; SP miglustat oral capsule 2 PA; LD; QL; SP YARGESA ORAL CAPSULE 2 PA; LD; QL; SP *AMINO ACIDS*** l-glutamine oral packet 4 PA; LD; SP *COBALAMINS*** cyanocobalamin injection solution 1000 mcg/ml 1 or 1a* hydroxocobalamin acetate intramuscular solution 1 or 1b* *CYTOTOXIC AGENTS*** DROXIA ORAL CAPSULE 2 Drug Name Tier Notes *ERYTHROPOIESIS- STIMULATING AGENTS (ESAS)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML 4 PA; LD; QL; SP ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP PROCRIT INJECTION SOLUTION 4 PA; LD; QL; SP RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML 4 PA; LD; QL; SP *FOLIC ACID/FOLATE COMBINATIONS*** foltabs 800 oral tablet 1 or 1b* $0 *FOLIC ACID/FOLATES*** cvs folic acid oral tablet 800 mcg 1 or 1a* $0 fa-8 oral capsule 1 or 1b* $0 folate oral tablet 1 or 1a* $0 folic acid injection solution 1 or 1a* folic acid oral capsule 0.8 mg 1 or 1b* $0 folic acid oral tablet 1 mg 1 or 1a* folic acid oral tablet 400 mcg, 800 mcg 1 or 1a* $0 ft folic acid oral tablet 1 or 1a* $0 gnp folic acid oral tablet 1 or 1a* $0 kp folic acid oral tablet 800 mcg 1 or 1a* $0 qc folic acid oral tablet 1 or 1a* $0 ra folic acid oral tablet 1 or 1a* $0 true folic acid oral tablet 400 mcg 1 or 1a* $0 yl folic acid oral tablet 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 58