Drug Name Tier Notes galantamine hydrobromide er oral capsule extended release 24 hour 8 mg 2 DO galantamine hydrobromide oral solution 2 QL galantamine hydrobromide oral tablet 12 mg, 8 mg 2 QL galantamine hydrobromide oral tablet 4 mg 2 DO rivastigmine tartrate oral capsule 1.5 mg, 3 mg 2 DO rivastigmine tartrate oral capsule 4.5 mg, 6 mg 2 QL rivastigmine transdermal patch 24 hour 2 QL *MOVEMENT DISORDER DRUG THERAPY*** AUSTEDO ORAL TABLET 4 PA; LD; QL; SP AUSTEDO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 PA; LD; QL; SP AUSTEDO XR PATIENT TITRATION ORAL TABLET EXTENDED RELEASE THERAPY PACK 12 & 18 & 24 & 30 MG 4 PA; LD; QL; SP INGREZZA ORAL CAPSULE 40 MG 4 PA; LD; DO; SP INGREZZA ORAL CAPSULE 60 MG, 80 MG 4 PA; LD; QL; SP INGREZZA ORAL CAPSULE SPRINKLE 40 MG 4 PA; LD; DO; SP INGREZZA ORAL CAPSULE SPRINKLE 60 MG, 80 MG 4 PA; LD; QL; SP INGREZZA ORAL CAPSULE THERAPY PACK 4 PA; LD; QL; SP tetrabenazine oral tablet 4 PA; LD; QL; SP *MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS*** teriflunomide oral tablet 4 PA; LD; QL; SP Drug Name Tier Notes *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (6 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (7 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP MAVENCLAD (9 TABS) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS - INTERFERONS*** AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 4 PA; LD; QL; SP AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 4 PA; LD; QL; SP BETASERON SUBCUTANEOUS KIT 4 PA; LD; QL; SP PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP PLEGRIDY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 82