HIV
PDL Reference Documents
Drug Use Review Documents
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.
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 | ABACAVIR | TABLET | Y | ||
abacavir sulfate/lamivudine | EPZICOM | TABLET | Y | ||
abacavir sulfate/lamivudine | ABACAVIR-LAMIVUDINE | TABLET | Y | ||
abacavir/dolutegravir/lamivudi | TRIUMEQ PD | TAB SUSP | Y | ||
abacavir/dolutegravir/lamivudi | TRIUMEQ | TABLET | Y | ||
abacavir/lamivudine/zidovudine | TRIZIVIR | TABLET | Y | ||
atazanavir sulfate | ATAZANAVIR SULFATE | CAPSULE | Y | ||
atazanavir sulfate | REYATAZ | CAPSULE | Y | ||
atazanavir sulfate | REYATAZ | POWD PACK | Y | ||
atazanavir sulfate/cobicistat | EVOTAZ | TABLET | Y | ||
bictegrav/emtricit/tenofov ala | BIKTARVY | TABLET | Y | ||
cabotegravir | CABOTEGRAVIR ER (CABENUVA) | SUSER VIAL | Y | ||
cabotegravir | APRETUDE | SUSER VIAL | Y | ||
cabotegravir sodium | VOCABRIA | TABLET | Y | Aug 05, 2021 | |
cabotegravir/rilpivirine | CABENUVA | SUSER VIAL | Y | Aug 05, 2021 | |
cobicistat | TYBOST | TABLET | Y | ||
darunavir | PREZISTA | ORAL SUSP | Y | ||
darunavir | PREZISTA | TABLET | Y | ||
darunavir | DARUNAVIR | TABLET | Y | ||
darunavir/cob/emtri/tenof alaf | SYMTUZA | TABLET | Y | ||
darunavir/cobicistat | PREZCOBIX | TABLET | Y | ||
dolutegravir sodium | TIVICAY PD | TAB SUSP | Y | ||
dolutegravir sodium | TIVICAY | TABLET | Y | ||
dolutegravir sodium/lamivudine | DOVATO | TABLET | Y | ||
dolutegravir/rilpivirine | JULUCA | TABLET | Y | ||
doravirine | PIFELTRO | TABLET | Y | ||
doravirine/lamivu/tenofov diso | DELSTRIGO | TABLET | Y | ||
efavirenz | EFAVIRENZ | CAPSULE | Y | ||
efavirenz | EFAVIRENZ | TABLET | Y | ||
efavirenz/emtricit/tenofovr df | EFAVIRENZ-EMTRIC-TENOFOV DISOP | TABLET | Y | ||
efavirenz/emtricit/tenofovr df | ATRIPLA | TABLET | Y | ||
efavirenz/lamivu/tenofov disop | SYMFI LO | TABLET | Y | ||
efavirenz/lamivu/tenofov disop | SYMFI | TABLET | Y | ||
efavirenz/lamivu/tenofov disop | EFAVIRENZ-LAMIVU-TENOFOV DISOP | 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 | EMTRICITABINE | CAPSULE | Y | ||
emtricitabine | EMTRIVA | SOLUTION | Y | ||
emtricitabine/tenofov alafenam | DESCOVY | TABLET | Y | ||
emtricitabine/tenofovir (TDF) | TRUVADA | TABLET | Y | ||
emtricitabine/tenofovir (TDF) | EMTRICITABINE-TENOFOVIR DISOP | TABLET | Y | ||
enfuvirtide | FUZEON | VIAL | Y | ||
etravirine | INTELENCE | TABLET | Y | ||
etravirine | ETRAVIRINE | TABLET | Y | ||
fosamprenavir calcium | FOSAMPRENAVIR CALCIUM | TABLET | Y | ||
fosamprenavir calcium | LEXIVA | TABLET | Y | ||
fostemsavir tromethamine | RUKOBIA | TAB ER 12H | Y | ||
ibalizumab-uiyk | TROGARZO | VIAL | Y | ||
lamivudine | LAMIVUDINE | SOLUTION | Y | ||
lamivudine | EPIVIR | SOLUTION | Y | ||
lamivudine | LAMIVUDINE | TABLET | Y | ||
lamivudine | EPIVIR | TABLET | Y | ||
lamivudine/tenofovir disop fum | CIMDUO | TABLET | Y | ||
lamivudine/zidovudine | LAMIVUDINE-ZIDOVUDINE | TABLET | Y | ||
lamivudine/zidovudine | COMBIVIR | TABLET | Y | ||
lenacapavir sodium | SUNLENCA | TABLET | Y | ||
lenacapavir sodium | SUNLENCA | VIAL | Y | ||
lopinavir/ritonavir | LOPINAVIR-RITONAVIR | SOLUTION | Y | ||
lopinavir/ritonavir | KALETRA | SOLUTION | Y | ||
lopinavir/ritonavir | KALETRA | TABLET | Y | ||
lopinavir/ritonavir | LOPINAVIR-RITONAVIR | TABLET | Y | ||
maraviroc | SELZENTRY | SOLUTION | Y | ||
maraviroc | SELZENTRY | TABLET | Y | ||
maraviroc | MARAVIROC | TABLET | Y | ||
nevirapine | NEVIRAPINE | ORAL SUSP | Y | ||
nevirapine | VIRAMUNE XR | TAB ER 24H | Y | ||
nevirapine | NEVIRAPINE ER | 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 | TABLET | Y | ||
raltegravir potassium | ISENTRESS HD | TABLET | Y | ||
rilpivirine | RILPIVIRINE ER (CABENUVA) | SUSER VIAL | Y | ||
rilpivirine HCl | EDURANT | TABLET | Y | ||
ritonavir | NORVIR | POWD PACK | Y | ||
ritonavir | RITONAVIR | TABLET | Y | ||
ritonavir | NORVIR | TABLET | Y | ||
tipranavir | APTIVUS | CAPSULE | Y | ||
zidovudine | RETROVIR | CAPSULE | Y | ||
zidovudine | ZIDOVUDINE | CAPSULE | Y | ||
zidovudine | RETROVIR | SYRUP | Y | ||
zidovudine | ZIDOVUDINE | SYRUP | Y | ||
zidovudine | ZIDOVUDINE | TABLET | Y | ||
zidovudine | RETROVIR | VIAL | Y | ||
nelfinavir mesylate | VIRACEPT | TABLET | N | ||
stavudine | STAVUDINE | CAPSULE | N |