Drug Name Tier Notes SIMLANDI (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML 4 PA; LD; QL SIMPONI ARIA INTRAVENOUS SOLUTION 4 PA; LD; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; QL; SP *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** celecoxib oral capsule 2 QL *GOLD COMPOUNDS*** RIDAURA ORAL CAPSULE 2 QL *NONSTEROIDAL ANTI- INFLAMMATORY AGENT COMBINATIONS*** diclofenac-misoprostol oral tablet delayed release 2 QL *NONSTEROIDAL ANTI- INFLAMMATORY AGENTS (NSAIDS)*** diclofenac potassium oral tablet 50 mg 1 or 1b* QL diclofenac sodium er oral tablet extended release 24 hour 1 or 1b* QL diclofenac sodium oral tablet delayed release 1 or 1b* QL ec-naproxen oral tablet delayed release 1 or 1b* etodolac er oral tablet extended release 24 hour 1 or 1b* QL etodolac oral capsule 1 or 1b* QL etodolac oral tablet 1 or 1b* QL flurbiprofen oral tablet 1 or 1b* QL ibu oral tablet 1 or 1a* QL ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 or 1a* QL indomethacin er oral capsule extended release 1 or 1b* QL Drug Name Tier Notes indomethacin oral capsule 25 mg, 50 mg 1 or 1b* QL ketoprofen er oral capsule extended release 24 hour 1 or 1b* QL ketorolac tromethamine injection solution 15 mg/ml 2 QL KETOROLAC TROMETHAMINE INJECTION SOLUTION 30 MG/ML 2 QL ketorolac tromethamine intramuscular solution 60 mg/2ml 2 QL ketorolac tromethamine oral tablet 1 or 1a* QL meclofenamate sodium oral capsule 1 or 1b* QL mefenamic acid oral capsule 1 or 1b* QL meloxicam oral tablet 1 or 1b* QL nabumetone oral tablet 1 or 1b* QL naproxen dr oral tablet delayed release 500 mg 1 or 1b* naproxen oral tablet 1 or 1b* QL naproxen oral tablet delayed release 1 or 1b* naproxen sodium oral tablet 275 mg, 550 mg 1 or 1b* QL oxaprozin oral tablet 1 or 1b* QL piroxicam oral capsule 1 or 1b* QL sulindac oral tablet 1 or 1b* QL tolmetin sodium oral capsule 2 QL *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** OTEZLA ORAL TABLET 4 PA; LD; QL; SP OTEZLA ORAL TABLET THERAPY PACK 4 PA; LD; QL; SP *PYRIMIDINE SYNTHESIS INHIBITORS*** leflunomide oral tablet 2 QL *SELECTIVE COSTIMULATION MODULATORS*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- INJECTOR 4 PA; LD; QL; SP * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 10