Drug Name Tier Notes eql aspirin low dose oral tablet delayed release 1 or 1a* $0 ft aspirin low dose oral tablet delayed release 1 or 1a* $0 ft aspirin oral tablet chewable 1 or 1a* $0 gnp adult aspirin low strength oral tablet chewable 1 or 1a* $0 gnp aspirin low dose oral tablet delayed release 1 or 1a* $0 gnp aspirin oral tablet delayed release 81 mg 1 or 1a* $0 goodsense aspirin low dose oral tablet delayed release 1 or 1a* $0 goodsense aspirin oral tablet chewable 1 or 1a* $0 h-e-b aspirin oral tablet delayed release 1 or 1a* $0 kls aspirin low dose oral tablet delayed release 1 or 1a* $0 kp aspirin oral tablet delayed release 1 or 1a* $0 mm aspirin oral tablet delayed release 1 or 1a* $0 qc aspirin low dose oral tablet chewable 1 or 1a* $0 qc aspirin low dose oral tablet delayed release 1 or 1a* $0 qc childrens aspirin oral tablet chewable 1 or 1a* $0 ra aspirin adult low dose oral tablet chewable 1 or 1a* $0 ra aspirin adult low strength oral tablet chewable 1 or 1a* $0 ra aspirin childrens oral tablet chewable 1 or 1a* $0 ra aspirin ec adult low st oral tablet delayed release 1 or 1a* $0 ra aspirin ec oral tablet delayed release 81 mg 1 or 1a* $0 sb childrens aspirin oral tablet chewable 1 or 1a* $0 sb low dose asa ec oral tablet delayed release 1 or 1a* $0 st joseph aspirin oral tablet delayed release 1 or 1a* $0 st joseph low dose oral tablet chewable 1 or 1a* $0 st joseph low dose oral tablet delayed release 1 or 1a* $0 Drug Name Tier Notes *ANALGESICS - OPIOID* *CODEINE COMBINATIONS*** acetaminophen-codeine oral solution 1 or 1a* AL; QL acetaminophen-codeine oral tablet 1 or 1a* AL; QL ascomp-codeine oral capsule 1 or 1b* AL; QL butalbital-apap-caff-cod oral capsule 1 or 1b* AL; QL butalbital-asa-caff-codeine oral capsule 1 or 1b* AL; QL *DIHYDROCODEINE COMBINATIONS*** apap-caff-dihydrocodeine oral capsule 1 or 1b* QL trezix oral capsule 320.5-30- 16 mg 1 or 1b* QL *HYDROCODONE COMBINATIONS*** hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 2.5-108 mg/5ml, 5- 217 mg/10ml, 7.5-325 mg/15ml 1 or 1b* QL hydrocodone-acetaminophen oral tablet 10-300 mg, 10- 325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg 1 or 1b* QL hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg 1 or 1b* QL *OPIOID AGONISTS*** codeine sulfate oral tablet 30 mg 2 AL; QL FENTANYL CITRATE (PF) INJECTION SOLUTION 100 MCG/2ML, 250 MCG/5ML 1 or 1b* fentanyl citrate (pf) injection solution 1000 mcg/20ml, 2500 mcg/50ml, 500 mcg/10ml 1 or 1b* fentanyl transdermal patch 72 hour 2 PA; QL hydrocodone bitartrate er oral tablet er 24 hour abuse- deterrent 1 or 1b* PA; QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 12