Drug Name Tier Notes PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS*** dimethyl fumarate oral capsule delayed release 1 or 1b* PA; LD; QL; SP dimethyl fumarate starter pack oral capsule delayed release therapy pack 1 or 1b* PA; LD; QL; SP VUMERITY ORAL CAPSULE DELAYED RELEASE 4 PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS*** dalfampridine er oral tablet extended release 12 hour 1 or 1b* PA; LD; QL; SP *MULTIPLE SCLEROSIS AGENTS*** COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML 4 PA; LD; QL; SP glatiramer acetate subcutaneous solution prefilled syringe 4 PA; LD; QL; SP glatopa subcutaneous solution prefilled syringe 4 PA; LD; QL; SP Drug Name Tier Notes *N-METHYL-D- ASPARTATE (NMDA) RECEPTOR ANTAGONISTS*** memantine hcl er oral capsule extended release 24 hour 14 mg, 7 mg 2 DO memantine hcl er oral capsule extended release 24 hour 21 mg, 28 mg 2 QL memantine hcl oral solution 2 QL memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg 2 QL memantine hcl oral tablet 5 mg 2 DO *PHENOTHIAZINES & TRICYCLIC AGENTS*** perphenazine-amitriptyline oral tablet 1 or 1b* AL *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** gabapentin (once-daily) oral tablet 2 PA; DO pregabalin er oral tablet extended release 24 hour 165 mg, 82.5 mg 2 PA; DO pregabalin er oral tablet extended release 24 hour 330 mg 2 PA; QL *PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS*** fluoxetine hcl (pmdd) oral tablet 10 mg 1 or 1b* DO fluoxetine hcl (pmdd) oral tablet 20 mg 1 or 1b* QL *PSYCHOTHERAPEUTI C AND NEUROLOGICAL AGENTS - MISC.*** pimozide oral tablet 1 or 1b* AL; QL *SMOKING DETERRENTS*** bupropion hcl er (smoking det) oral tablet extended release 12 hour 1 or 1b* $0; QL cvs nicotine mouth/throat gum 1 or 1b* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 83