Drug Name Tier Notes hydromorphone hcl er oral tablet extended release 24 hour 2 PA; QL hydromorphone hcl injection solution 4 mg/ml 1 or 1b* hydromorphone hcl oral liquid 1 or 1b* QL hydromorphone hcl oral tablet 1 or 1b* QL hydromorphone hcl pf injection solution 50 mg/5ml, 500 mg/50ml 1 or 1b* levorphanol tartrate oral tablet 3 mg 2 PA; QL meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml 1 or 1b* meperidine hcl oral solution 1 or 1b* QL meperidine hcl oral tablet 50 mg 1 or 1b* QL methadone hcl intensol oral concentrate 1 or 1b* PA; QL methadone hcl oral concentrate 1 or 1b* PA; QL methadone hcl oral solution 1 or 1b* PA; QL methadone hcl oral tablet 1 or 1b* PA; QL methadone hcl oral tablet soluble 1 or 1b* PA; QL methadose oral tablet soluble 1 or 1b* PA; QL mitigo injection solution 2 morphine sulfate (concentrate) oral solution 100 mg/5ml 1 or 1b* QL morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml 1 or 1b* morphine sulfate er beads oral capsule extended release 24 hour 2 PA; QL morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 2 PA; QL morphine sulfate er oral tablet extended release 2 PA; QL morphine sulfate intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml 1 or 1b* morphine sulfate oral solution 1 or 1b* QL Drug Name Tier Notes morphine sulfate oral tablet 1 or 1b* QL oxycodone hcl oral capsule 2 QL oxycodone hcl oral concentrate 100 mg/5ml 2 QL oxycodone hcl oral solution 2 QL oxycodone hcl oral tablet 2 QL oxymorphone hcl er oral tablet extended release 12 hour 2 PA; QL oxymorphone hcl oral tablet 2 QL remifentanil hcl intravenous solution reconstituted 1 or 1b* SUFENTANIL CITRATE INTRAVENOUS SOLUTION 1 or 1b* tramadol hcl (er biphasic) oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg 2 PA; QL tramadol hcl (er biphasic) oral tablet extended release 24 hour 2 PA; QL tramadol hcl er oral tablet extended release 24 hour 2 PA; QL tramadol hcl oral tablet 100 mg, 50 mg 1 or 1b* AL; QL tramadol hcl oral tablet 25 mg 2 PA; QL *OPIOID COMBINATIONS*** endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1 or 1b* QL OXYCODONE- ACETAMINOPHEN ORAL SOLUTION 5-325 MG/5ML 1 or 1b* QL oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- 325 mg, 5-325 mg, 7.5-325 mg 1 or 1b* QL *OPIOID PARTIAL AGONISTS*** buprenorphine hcl injection solution 0.3 mg/ml 2 buprenorphine hcl sublingual tablet sublingual 1 or 1b* QL buprenorphine hcl-naloxone hcl sublingual film 1 or 1b* QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 13