HIV

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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 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 TRIZIVIR TABLET Y    
ABACAVIR/LAMIVUDINE/ZIDOVUDINE ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABLET Y    
ATAZANAVIR SULFATE REYATAZ 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 SUSTIVA TABLET Y    
EFAVIRENZ/EMTRICITAB/TENOFOVIR 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    
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 NEVIRAPINE ER TAB ER 24H Y    
NEVIRAPINE VIRAMUNE XR TAB ER 24H Y    
NEVIRAPINE VIRAMUNE TABLET Y    
NEVIRAPINE NEVIRAPINE 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    
STAVUDINE STAVUDINE 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