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HIV Carve-in Benefit Information

As of January 1, 2020, all HIV medications were carved in as a pharmacy benefit from Maryland Medicaid to be managed by medicaid recipients' individual Managed Care Organization (MCO). Members (who were on HIV therapy prior to 1/1/2020) were given a 180 day transitional prior authorization for each medication in their HIV regimen. The transitional prior authorization will end as of June 30, 2020. MPC recommends that you prescribe a formulary preferred medication(s) highlighted below, or submit a new request for a non-preferred medication(s) using the forms below to minimize therapeutic disruption. 

Resources:


Prior Authorization Forms For HIV Drug Classes

These forms should be faxed to 877-251-5896 to be processed through Express Scripts, Inc. (ESI).

* Preferred medication is on formulary without a prior authorization requirement and is qualified for a 90-days' supply. 

CCR5 Antagonists (PDF)

Non-Preferred

  • Selzentry® (maraviroc)

Combination Regimen (Single Therapy Regimen) (PDF)

Preferred (no PA required)

  • BIKTARVY® (bictegravir/emtricitabine/tenofovir/alafenamide)*
  • SYMFI® (efavirenz/lamivudine/tenofovir disoproxil fumarate)*
  • SYMFI LO® (efavirenz/lamivudine/tenofovir disoproxil fumarate)*
Non-Preferred
 
  • Atripla® (efavirenz/emtricitabine/tenofovir disoproxil fumarate)
  • Complera® (emtricitabine/rilpivirine/tenofovir disoproxil fumarate)
  • Genvoya® (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide)
  • Odefsey® (emtricitabine/rilpivirine/tenofovir alafenamide)
  • Stribild® (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate)
  • Triumeq® (abacavir/dolutegravir/lamivudine)
  • Juluca® (dolutegravir/rilpivirine) 
  • Dovato® (dolutegravir/lamivudine) 
  • Symtuza® (darunavir/cobicistat/emtricitabine/tenofovir alafenamide)
  • Delstrigo® (doravirine/lamivudine/tenofovir disoproxil) 
  • Temixys® (lamivudine/tenofovir disoproxil fumarate)

Integrase Inhibitors (PDF)

Preferred (no PA required)

  • ISENTRESS® (raltegravir)*
Non-Preferred
 
  • Tivicay® (dolutegravir)

Nucleotide/side Reverse Transcriptase Inhibitors (NRTIs) (PDF)

Preferred (no PA required)

  • CIMDUO® (lamivudine/tenofovir/disoproxil fumarate)*
  • EPIVIR® (lamivudine)*
  • RETROVIR® (zidovudine)*
  • TRUVADA (tenofovir disoproxil fumarate/emtricitabine)*
  • VIREAD® (tenofovir disoproxil fumarate)*
  • ZIAGEN® (abacavir)*
Non-Preferred
 
  • Combivir® (zidovudine/lamivudine)
  • Descovy® (emtricitabine/tenofovir alafenamide) 
  • Emtriva® (emtricitabine; FTC) 
  • Epzicom® (abacavir/ lamivudine) 
  • Trizivir® (abacavir/zidovudone/lamivudine) 
  • Videx® (didanosine)
  • Zerit® (stavudine; d4T)

Nucleoside Reverse Transcriptase Inhibitors, non-nukes (NNRTIs) (PDF)

Preferred (no PA required)

  • VIRAMUNE® (nevirapine)*
  • VIRAMUNE XR® (nevirapine)*
Non-Preferred
 
  • Edurant® (rilprivine) 
  • Intelence® (etravirine)
  • Pifeltro® (doravirine)
  • Rescriptor® (delaviridine)
  • Sustiva® (efavirenz)

Protease Inhibitors (PDF)

Preferred (no PA required)

  • NORVIR® (ritonavir)*
  • KALETRA® (lopinavir/ritonavir)*
  • REYATAZ® (atazanavir)*
Non-Preferred
 
  • Aptivus® (tipranavir) 
  • Crixivan® (indinavir) 
  • Evotaz® (atazanavir/cobicistat) 
  • Invirase® (saquinavir) 
  • Lexiva® (fosamprenavir) 
  • Prezcobix® (darunavir/cobicistat) 
  • Prezista® (darunavir) 
  • Viracept® (nelfinavir)

 

MPC Reviewed HIV Medications by Drug Class

The requests for the following medications should be faxed to 866-207-7231 to be processed by MPC's Pharmacy Department using the Pharmacy Coverage Determination Request Form (PDF).

HIV-1 Fusion Inhibitor

Non-Preferred 

  • Fuzeon® (enfuvirtide)

CD4-Directed Post-Attachment HIV-1 Inhibitor

Non-Prefered

  • Trogarzo® (ibalizumab-uiyk)