Drug Name Tier Notes KISQALI (600 MG DOSE) ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP VERZENIO ORAL TABLET 4 PA; LD; QL; SP *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** leucovorin calcium injection solution 1 or 1b* LD leucovorin calcium injection solution reconstituted 1 or 1b* LD leucovorin calcium oral tablet 2 *GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS*** FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL; SP FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG 4 PA; LD; QL; SP ORGOVYX ORAL TABLET 4 PA; LD; QL *IMIDAZOTETRAZINES *** temozolomide oral capsule 4 PA; LD; QL; SP *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** JAKAFI ORAL TABLET 4 PA; LD; QL; SP *LHRH ANALOGS*** leuprolide acetate injection kit 4 PA; LD; SP TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 PA; LD; QL; SP *MITOTIC INHIBITORS*** etoposide oral capsule 4 LD; SP *NITROGEN MUSTARDS AND RELATED ANALOGUES*** cyclophosphamide oral capsule 4 LD; SP Drug Name Tier Notes LEUKERAN ORAL TABLET 2 LD *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** LYNPARZA ORAL TABLET 4 PA; LD; QL; SP ZEJULA ORAL TABLET 4 PA; LD; QL; SP *PROGESTINS- ANTINEOPLASTIC*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 800 mg/20ml 1 or 1b* LD megestrol acetate oral tablet 1 or 1b* LD *RETINOIDS*** tretinoin oral capsule 2 LD *SELECTIVE RETINOID X RECEPTOR AGONISTS*** bexarotene oral capsule 4 PA; LD; QL; SP *TOPOISOMERASE I INHIBITORS*** HYCAMTIN ORAL CAPSULE 4 PA; LD; SP *URINARY TRACT PROTECTIVE AGENTS*** mesna intravenous solution 1 or 1b* PA; LD mesna oral tablet 2 PA; LD *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS*** AVASTIN INTRAVENOUS SOLUTION 4 PA; LD; SP INLYTA ORAL TABLET 2 PA; LD; QL; SP LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 33