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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 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 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 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

What HIV medications are covered and on formulary for MPC?

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

Where can I go to find MPC’s preferred HIV medications list and non-preferred prior authorization requirements?

These are posted on the MPC Website section – HIV-Carve-in Benefit Information.

What are the single-pill, complete regimen agents preferred by MPC?

Biktarvy, Symfi and Symfi Lo are the only preferred single-pill, complete regimen therapies for MPC.

What medication is covered for PrEP therapy?

MPC covers Truvada for as preferred PrEP therapy. Prior authorization is not required.

What is the process for requesting a prior authorization?

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.

Does MPC cover a 90 days’ supply of medications?

All preferred medications can be filled for a 90 day fill. Please note that the script must be written for 90 days in order to be dispensed for 90 days, per Maryland regulations.

Does MPC charge a member copay for HIV medications?

MPC does not charge its members a copay for any medications including HIV medications.

Will clinical documentation be required for prior authorization requests for HIV medication?

Clinical documentation may be required to support any prior authorization request.

Is prior authorization required for pediatric members less than 21 years old?

No, neither preferred agents nor non-preferred agents require prior authorization. All HIV medications are covered.

Does MPC allow an emergency fill override for HIV medications?

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.

Know The Facts About Coronavirus (COVID-19)

Symptoms are flu-like, including: fever, coughing, and shortness of breath.

If you think you might have been exposed, contact your doctor immediately. You can also have a video visit with a doctor using the MyVirtualMPC app.

It is important to do everything you can to protect yourself from COVID-19.

Notice

We are currently experiencing an issue with our Post Discharge and Clinical fax numbers. Please use these alternative numbers to fax this information to us:

Concurrent Review/Clinical Information: 833-694-1487

Post Discharge Services: 833-694-1485