HIV

← Back to Class List

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
abacavir sulfate ZIAGEN SOLUTION Y    
abacavir sulfate ABACAVIR SOLUTION Y    
abacavir sulfate ZIAGEN TABLET Y    
abacavir sulfate ABACAVIR TABLET Y    
abacavir sulfate/lamivudine EPZICOM TABLET Y    
abacavir sulfate/lamivudine ABACAVIR-LAMIVUDINE TABLET Y    
abacavir/dolutegravir/lamivudi TRIUMEQ TABLET Y    
abacavir/lamivudine/zidovudine ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABLET Y    
abacavir/lamivudine/zidovudine TRIZIVIR TABLET Y    
atazanavir sulfate REYATAZ CAPSULE Y    
atazanavir sulfate ATAZANAVIR SULFATE CAPSULE Y    
atazanavir sulfate REYATAZ POWD PACK Y    
atazanavir sulfate/cobicistat EVOTAZ TABLET Y    
cobicistat TYBOST TABLET Y    
darunavir ethanolate PREZISTA ORAL SUSP Y    
darunavir ethanolate PREZISTA TABLET Y    
darunavir/cobicistat PREZCOBIX TABLET Y    
delavirdine mesylate RESCRIPTOR TAB DISPER Y    
delavirdine mesylate RESCRIPTOR TABLET Y    
didanosine DIDANOSINE CAPSULE DR Y    
didanosine VIDEX EC CAPSULE DR Y    
didanosine VIDEX SOLN RECON Y    
dolutegravir sodium TIVICAY TABLET Y    
efavirenz SUSTIVA CAPSULE Y    
efavirenz EFAVIRENZ CAPSULE Y    
efavirenz SUSTIVA TABLET Y    
efavirenz/emtricit/tenofovr df ATRIPLA TABLET Y    
elviteg/cob/emtri/tenof alafen GENVOYA TABLET Y    
elviteg/cob/emtri/tenofo disop STRIBILD TABLET Y    
emtricita/rilpivirine/tenof DF COMPLERA TABLET Y    
emtricitab/rilpiviri/tenof ala ODEFSEY TABLET Y    
emtricitabine EMTRIVA CAPSULE Y    
emtricitabine EMTRIVA SOLUTION Y    
emtricitabine/tenofov alafenam DESCOVY TABLET Y    
emtricitabine/tenofovir (TDF) TRUVADA TABLET Y    
enfuvirtide FUZEON VIAL Y    
etravirine INTELENCE TABLET Y    
fosamprenavir calcium LEXIVA ORAL SUSP Y    
fosamprenavir calcium LEXIVA TABLET Y    
fosamprenavir calcium FOSAMPRENAVIR CALCIUM TABLET Y    
indinavir sulfate CRIXIVAN CAPSULE Y    
lamivudine LAMIVUDINE SOLUTION Y    
lamivudine EPIVIR SOLUTION Y    
lamivudine LAMIVUDINE TABLET Y    
lamivudine EPIVIR TABLET Y    
lamivudine/zidovudine LAMIVUDINE-ZIDOVUDINE TABLET Y    
lamivudine/zidovudine COMBIVIR TABLET Y    
lopinavir/ritonavir LOPINAVIR-RITONAVIR SOLUTION Y    
lopinavir/ritonavir KALETRA SOLUTION Y    
lopinavir/ritonavir KALETRA TABLET Y    
maraviroc SELZENTRY SOLUTION Y    
maraviroc SELZENTRY TABLET Y    
nelfinavir mesylate VIRACEPT TABLET Y    
nevirapine VIRAMUNE ORAL SUSP Y    
nevirapine VIRAMUNE XR TAB ER 24H Y    
nevirapine NEVIRAPINE ER TAB ER 24H Y    
nevirapine NEVIRAPINE TABLET Y    
nevirapine VIRAMUNE TABLET Y    
raltegravir potassium ISENTRESS POWD PACK Y    
raltegravir potassium ISENTRESS TAB CHEW Y    
raltegravir potassium ISENTRESS HD TABLET Y    
raltegravir potassium ISENTRESS TABLET Y    
rilpivirine HCl EDURANT TABLET Y    
ritonavir NORVIR SOLUTION Y    
ritonavir NORVIR TABLET Y    
saquinavir mesylate INVIRASE CAPSULE Y    
saquinavir mesylate INVIRASE TABLET Y    
stavudine ZERIT CAPSULE Y    
stavudine STAVUDINE CAPSULE Y    
stavudine ZERIT SOLN RECON Y    
tipranavir APTIVUS CAPSULE Y    
tipranavir/vitamin E TPGS APTIVUS SOLUTION Y    
zidovudine ZIDOVUDINE CAPSULE Y    
zidovudine RETROVIR CAPSULE Y    
zidovudine ZIDOVUDINE SYRUP Y    
zidovudine RETROVIR SYRUP Y    
zidovudine ZIDOVUDINE TABLET Y    
zidovudine RETROVIR VIAL Y