Drug Name Tier Notes TRIUMEQ ORAL TABLET 4 LD; QL TRIUMEQ PD ORAL TABLET SOLUBLE 4 LD; QL *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** maraviroc oral tablet 4 LD; QL *ANTIRETROVIRALS - FUSION INHIBITORS*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; QL *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** ISENTRESS ORAL TABLET 4 LD; QL ISENTRESS ORAL TABLET CHEWABLE 4 LD; QL TIVICAY ORAL TABLET 50 MG 4 LD; QL TIVICAY PD ORAL TABLET SOLUBLE 4 LD; QL *ANTIRETROVIRALS - PROTEASE INHIBITORS*** APTIVUS ORAL CAPSULE 4 PA; LD; QL atazanavir sulfate oral capsule 4 LD; QL darunavir oral tablet 4 LD; QL fosamprenavir calcium oral tablet 4 LD; QL PREZISTA ORAL SUSPENSION 4 LD; QL PREZISTA ORAL TABLET 150 MG, 75 MG 4 LD; QL REYATAZ ORAL PACKET 4 LD; QL ritonavir oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES*** EDURANT ORAL TABLET 4 PA; LD; QL efavirenz oral tablet 4 LD; QL etravirine oral tablet 4 PA; LD; QL Drug Name Tier Notes INTELENCE ORAL TABLET 25 MG 4 PA; LD; QL nevirapine er oral tablet extended release 24 hour 400 mg 4 LD; QL nevirapine oral suspension 4 LD; QL nevirapine oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PURINES*** abacavir sulfate oral solution 4 LD; QL abacavir sulfate oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PYRIMIDINES*** emtricitabine oral capsule 4 LD; $0; QL EMTRIVA ORAL SOLUTION 4 LD; QL lamivudine oral solution 4 LD; QL lamivudine oral tablet 150 mg, 300 mg 4 PA; LD; QL *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- THYMIDINES*** zidovudine oral capsule 4 LD; QL zidovudine oral syrup 4 LD; QL zidovudine oral tablet 4 LD; QL *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** tenofovir disoproxil fumarate oral tablet 4 LD; $0; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG 4 LD; QL *ANTIVIRAL COMBINATIONS*** PAXLOVID (150/100) ORAL TABLET THERAPY PACK 2 QL PAXLOVID (300/100 & 150/100) ORAL TABLET THERAPY PACK 2 QL PAXLOVID (300/100) ORAL TABLET THERAPY PACK 2 QL * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 37