Drug Name Tier Notes HUMATROPE INJECTION CARTRIDGE 4 PA; LD; QL; SP SKYTROFA SUBCUTANEOUS CARTRIDGE 4 PA; LD; QL; SP *HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS*** nitisinone oral capsule 10 mg, 2 mg, 5 mg 4 PA; LD; SP nitisinone oral capsule 20 mg 4 PA; LD *HOMOCYSTINURIA TREATMENT - AGENTS*** betaine oral powder 4 LD *HYPERAMMONEMIA TREATMENT - AGENTS*** carglumic acid oral tablet soluble 4 PA; LD *HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS*** calcitriol intravenous solution 1 mcg/ml 1 or 1b* PA calcitriol oral capsule 1 or 1b* PA calcitriol oral solution 2 PA doxercalciferol intravenous solution 2 PA doxercalciferol oral capsule 2 PA paricalcitol oral capsule 2 PA *HYPOPHOSPHATASIA (HPP) AGENTS*** STRENSIQ SUBCUTANEOUS SOLUTION 4 PA; LD *LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS*** SYNAREL NASAL SOLUTION 4 PA; LD; QL; SP *OVULATION STIMULANTS- GONADOTROPINS*** GONAL-F INJECTION SOLUTION RECONSTITUTED 4 PA; LD; SP Drug Name Tier Notes GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION PEN- INJECTOR 300 UNIT/0.5ML, 450 UNT/0.75ML 4 PA; LD; SP GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION PEN- INJECTOR 900 UNT/1.44ML 4 PA GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT 4 PA; LD; SP *OVULATION STIMULANTS- SYNTHETIC*** CLOMID ORAL TABLET 1 or 1b* PA clomiphene citrate oral tablet 1 or 1b* PA *PHENYLKETONURIA TREATMENT - AGENTS*** JAVYGTOR ORAL PACKET 4 PA; LD JAVYGTOR ORAL TABLET 4 PA; LD sapropterin dihydrochloride oral packet 4 PA; LD; SP sapropterin dihydrochloride oral tablet 4 PA; LD; SP *RANK LIGAND (RANKL) INHIBITORS*** PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)*** raloxifene hcl oral tablet 1 or 1b* $0; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 53