Pharmacy Prior Authorization Criteria

HIV PEP/PrEP - Copay Waiver

Indicated in combination with other antiretrovirals for the treatment of human immunodeficiency virus type 1 (HIV‑1) infection

Indicated, in combination with other antiretroviral agents, for the treatment of HIV-1 infection in adults and pediatric patients weighing at least 35 kg
Indicated, in combination with other antiretroviral agents other than protease inhibitors that require a CYP3A inhibitor, for the treatment of HIV-1 infection in pediatric patients weighing at least 14 kg and less than 35 kg
Indicated in at-risk adults and adolescents weighing at least 35 kg for pre-exposure prophylaxis (PrEP) to reduce the risk of HIV-1 infection from sexual acquisition, excluding individuals at risk from receptive vaginal sex. Individuals must have a

Indicated in combination with other antiretroviral agents for the treatment of human immunodeficiency virus (HIV-1) infection in adult patients
Indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in pediatric patients 4 weeks of age and older
Indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in pediatric patients weighing at least 40 kg

Indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection
Indicated for the prevention of maternal-fetal HIV-1 transmission

Indicated in combination with other antiretroviral agents for the treatment of HIV‑1 infection in adults (treatment-naïve or -experienced) and in pediatric patients (treatment-naïve or -experienced but integrase strand transfer inhibitor [INSTI]-na
Indicated in combination with rilpivirine as a complete regimen for the treatment of HIV-1 infection in adults to replace the current antiretroviral regimen in those who are virologically suppressed (HIV-1 RNA less than 50 copies/ mL) on a stable a

Indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients weighing at least 17 kg
Indicated in at-risk adults and adolescents weighing at least 35 kg for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 infection. Individuals must have a negative HIV-1 test immediately prior to initiating TRUVADA for

Indicated in combination with other antiretroviral agents for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and pediatric patients 2 years of age and older weighing at least 10 kg
Indicated for the treatment of chronic hepatitis B virus (HBV) in adults and pediatric patients 2 years of age and older weighing at least 10 kg

Copay Waiver (Initial Authorization)

Length of Approval: 1 Year(s)
For diagnosis of HIV PEP and PrEP

The medication is being used for HIV-1 pre-exposure prophylaxis (PrEP) or HIV-1 post-exposure prophylaxis (PEP)

Copay Waiver (Reauthorization)

Length of Approval: 1 Year(s)
For diagnosis of HIV PEP and PrEP

The medication is being used for HIV-1 pre-exposure prophylaxis (PrEP) or HIV-1 post-exposure prophylaxis (PEP)

2024-12-19, 2024-12-17, 2024-11-25

Truvada Prescribing Information. Gilead Sciences, Inc. Foster City, CA. June 2020.
Descovy Prescribing Information. Gilead Sciences, Inc. Foster City, CA. January 2022.
Viread Prescribing Information. Gilead Sciences, Inc. Foster City, CA. April 2019.
Isentress Prescribing Information. Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. July 2017.
Tivicay Prescribing Information. GlaxoSmithKline. Durham, NC. October 2022.
Combivir Prescribing Information. GlaxoSmithKline. Research Triangle Park, NC. May 2019
Epivir Prescribing Information. Research Triangle Park, NC. November 2020.
Retrovir Prescribing Information. ViiV Healthcare. Durham, NC. June 2023.
Kaletra Prescribing Information. AbbVie Inc. North Chicago, IL. April 2023.