Drug Name Tier Notes ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 4 PA; LD; QL; SP ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 4 PA; LD; QL; SP ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP *ANALGESICS - NONNARCOTIC* *ANALGESICS OTHER*** acetaminophen intravenous solution 1 or 1b* *ANALGESICS- SEDATIVES*** bac (butalbital-acetamin- caff) oral tablet 1 or 1b* QL butalbital-acetaminophen oral capsule 1 or 1b* QL butalbital-acetaminophen oral tablet 50-325 mg 1 or 1b* QL butalbital-apap-caffeine oral capsule 50-300-40 mg 1 or 1b* QL butalbital-apap-caffeine oral tablet 50-325-40 mg 1 or 1b* QL butalbital-aspirin-caffeine oral capsule 1 or 1b* QL tencon oral tablet 50-325 mg 1 or 1b* QL *SALICYLATES*** aspirin 81 oral tablet chewable 1 or 1a* $0 aspirin 81 oral tablet delayed release 1 or 1a* $0 aspirin adult low dose oral tablet delayed release 1 or 1a* $0 Drug Name Tier Notes aspirin adult low strength oral tablet delayed release 1 or 1a* $0 aspirin childrens oral tablet chewable 1 or 1a* $0 aspirin ec adult low dose oral tablet delayed release 1 or 1a* $0 aspirin ec low dose oral tablet delayed release 1 or 1a* $0 aspirin ec low strength oral tablet delayed release 1 or 1a* $0 aspirin low dose oral tablet chewable 1 or 1a* $0 aspirin low dose oral tablet delayed release 1 or 1a* $0 aspirin oral tablet chewable 1 or 1a* $0 aspirin oral tablet delayed release 81 mg 1 or 1a* $0 aspirin regimen oral tablet delayed release 1 or 1a* $0 bayer aspirin ec low dose oral tablet delayed release 1 or 1a* $0 bayer low dose oral tablet chewable 1 or 1a* $0 bayer low dose oral tablet delayed release 1 or 1a* $0 childrens aspirin oral tablet chewable 1 or 1a* $0 cvs aspirin adult low dose oral tablet chewable 1 or 1a* $0 cvs aspirin adult low strength oral tablet delayed release 1 or 1a* $0 cvs aspirin ec oral tablet delayed release 81 mg 1 or 1a* $0 cvs aspirin low dose oral tablet delayed release 1 or 1a* $0 cvs aspirin low strength oral tablet delayed release 1 or 1a* $0 diflunisal oral tablet 1 or 1b* QL ecotrin low strength oral tablet delayed release 1 or 1a* $0 eq aspirin adult low dose oral tablet delayed release 1 or 1a* $0 eq aspirin low dose oral tablet chewable 1 or 1a* $0 eq aspirin low dose oral tablet delayed release 1 or 1a* $0 eql aspirin low dose oral tablet chewable 1 or 1a* $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 11