Drug Name Tier Notes *CMV AGENTS*** valganciclovir hcl oral solution reconstituted 4 LD valganciclovir hcl oral tablet 4 LD *HEPATITIS B AGENTS*** adefovir dipivoxil oral tablet 4 PA; LD; QL; SP BARACLUDE ORAL SOLUTION 4 PA; LD; QL entecavir oral tablet 4 PA; LD; QL lamivudine oral tablet 100 mg 4 PA; LD; QL VEMLIDY ORAL TABLET 4 PA; LD; QL; SP *HEPATITIS C AGENT - COMBINATIONS*** EPCLUSA ORAL PACKET 4 PA; LD; QL; SP EPCLUSA ORAL TABLET 4 PA; LD; QL; SP HARVONI ORAL PACKET 4 PA; LD; QL; SP HARVONI ORAL TABLET 4 PA; LD; QL; SP VOSEVI ORAL TABLET 4 PA; LD; QL; SP *HEPATITIS C AGENTS*** ribavirin oral capsule 4 LD; QL; SP ribavirin oral tablet 200 mg 4 LD; QL; SP *HERPES AGENTS - PURINE ANALOGUES*** acyclovir oral capsule 1 or 1b* acyclovir oral suspension 1 or 1b* acyclovir oral tablet 1 or 1b* acyclovir sodium intravenous solution 1 or 1b* valacyclovir hcl oral tablet 1 or 1b* QL *HERPES AGENTS - THYMIDINE ANALOGUES*** famciclovir oral tablet 1 or 1b* QL *INFLUENZA AGENTS*** rimantadine hcl oral tablet 1 or 1b* Drug Name Tier Notes *MISC. ANTIVIRALS*** LAGEVRIO ORAL CAPSULE 3 QL *NEURAMINIDASE INHIBITORS*** oseltamivir phosphate oral capsule 1 or 1b* QL oseltamivir phosphate oral suspension reconstituted 1 or 1b* QL RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/ACT 2 QL *PA ENDONUCLEASE INHIBITORS*** XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 1 X 40 MG 3 QL XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 1 X 80 MG 3 QL *RSV AGENTS - NUCLEOSIDE ANALOGUES*** ribavirin inhalation solution reconstituted 2 *BETA BLOCKERS* *ALPHA-BETA BLOCKERS*** carvedilol oral tablet 1 or 1b* QL carvedilol phosphate er oral capsule extended release 24 hour 2 QL labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 or 1b* QL labetalol hcl oral tablet 400 mg 2 QL *BETA BLOCKERS CARDIO-SELECTIVE*** acebutolol hcl oral capsule 1 or 1b* atenolol oral tablet 1 or 1a* betaxolol hcl oral tablet 1 or 1b* bisoprolol fumarate oral tablet 1 or 1b* esmolol hcl intravenous solution 100 mg/10ml 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 08012025 38