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