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 ended 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 833-896-0656 to be processed through MPC Pharmacy PA Department.
*Preferred medication is on formulary without a prior authorization requirement
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)
Integrase Inhibitors
Preferred (no PA required)
- ISENTRESS® (raltegravir)*
- 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)
- Sustiva® (efavirenz)*
Non-Preferred
- Edurant® (rilprivine)
- Intelence® (etravirine)
- Pifeltro® (doravirine)
- Rescriptor® (delaviridine)
- VIRAMUNE® (nevirapine)
- VIRAMUNE XR® (nevirapine)
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 following medications’ requests should be faxed to 800-953-8856 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-Preferred
- Trogarzo® (ibalizumab-uiyk)
Frequently Asked Questions
All HIV medications are covered by MPC. MPC does have a list of preferred HIV agents. Non-preferred medications require prior authorization. You can find the medications by visiting here
These are posted on the MPC Website section – HIV-Carve-in Benefit Information.
Biktarvy, Symfi and Symfi Lo are the only preferred single-pill, complete regimen therapies for MPC.
MPC covers Truvada for as preferred PrEP therapy. Prior authorization is not required.
Providers retrieve an authorization form from the MPC Website and fax to ESI at 877-251-5896 or call ESI at 800-753-2851 for most prior authorization requests. Trogarzo and Fuzeon are reviewed by MPC’s Pharmacy Department. Fax authorization requests for these drugs to 800-953-8856.
No, MPC does not cover a 90 day supply of HIV medications.
MPC does not charge its members a copay for any medications including HIV medications.
Clinical documentation may be required to support any prior authorization request.
No, neither preferred agents nor non-preferred agents require prior authorization. All HIV medications are covered.
In the event of an actual emergency, a pharmacist may use his/her clinical judgment to approve a 30-day emergency fill for preferred medications and 14-day emergency fill for non-preferred medications.
