Drug Name Tier Notes *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ALKYLATING AGENTS*** MYLERAN ORAL TABLET 4 LD *ANDROGEN BIOSYNTHESIS INHIBITORS*** abiraterone acetate oral tablet 4 PA; LD; QL; SP ABIRTEGA ORAL TABLET 4 PA; LD; QL; SP *ANTIADRENALS*** LYSODREN ORAL TABLET 4 LD; QL *ANTIANDROGENS*** bicalutamide oral tablet 2 LD; QL ERLEADA ORAL TABLET 4 PA; LD; QL; SP nilutamide oral tablet 4 LD; QL NUBEQA ORAL TABLET 4 PA; LD; QL; SP XTANDI ORAL CAPSULE 4 PA; LD; QL; SP XTANDI ORAL TABLET 4 PA; LD; QL; SP *ANTIESTROGENS*** SOLTAMOX ORAL SOLUTION 2 LD; $0 tamoxifen citrate oral tablet 2 LD; $0 toremifene citrate oral tablet 4 LD *ANTIMETABOLITES*** capecitabine oral tablet 4 PA; LD; SP mercaptopurine oral suspension 2 PA; LD mercaptopurine oral tablet 2 LD methotrexate sodium (pf) injection solution 1 gm/40ml, 1000 mg/40ml, 250 mg/10ml, 50 mg/2ml 1 or 1b* LD methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 or 1b* LD methotrexate sodium injection solution reconstituted 1 or 1b* LD methotrexate sodium oral tablet 2 LD Drug Name Tier Notes TABLOID ORAL TABLET 2 LD TREXALL ORAL TABLET 2 ST; LD *ANTINEOPLASTIC - ALK INHIBITORS*** ALECENSA ORAL CAPSULE 2 PA; LD; QL; SP ALUNBRIG ORAL TABLET 2 PA; LD; QL ALUNBRIG ORAL TABLET THERAPY PACK 2 PA; LD; QL XALKORI ORAL CAPSULE 4 PA; LD; QL; SP *ANTINEOPLASTIC - ANTI-HER2 AGENTS*** HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG 4 LD; SP KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 4 LD; SP *ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS*** BOSULIF ORAL CAPSULE 2 PA; LD; QL; SP BOSULIF ORAL TABLET 2 PA; LD; QL; SP dasatinib oral tablet 1 or 1b* PA; LD; QL; SP imatinib mesylate oral tablet 1 or 1b* PA; LD; QL; SP nilotinib hcl oral capsule 4 PA; LD; QL; SP *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** TAFINLAR ORAL CAPSULE 4 PA; LD; QL; SP ZELBORAF ORAL TABLET 4 PA; LD; QL; SP *ANTINEOPLASTIC - BTK INHIBITORS*** CALQUENCE ORAL TABLET 4 PA; LD; QL IMBRUVICA ORAL CAPSULE 2 PA; LD; QL IMBRUVICA ORAL SUSPENSION 2 PA; LD; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 31