Pharmacy Prior Authorization Criteria

Atripla (efavirenz-emtricitabine-tenofovir disoproxil fumarate)

Indications for Prior Authorization

Atripla (efavirenz-emtricitabine-tenofovir disoproxil fumarate)

• For diagnosis of HIV-1 infection
  Indicated as a complete regimen or in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients weighing at least 40 kg.

Criteria

Atripla

Step Therapy

Length of Approval: 12 Month(s)

• All of the following:
• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to one of the following:
• Symfi (efavirenz-lamivudine-tenofovir DF)
• Symfi Lo (efavirenz-lamivudine-tenofovir DF)
• Triumeq (abacavir-dolutegravir-lamivudine)
• Juluca (dolutegravir-rilpivirine)
• Cimduo (lamivudine-tenofovir DF) plus Isentress (raltegravir)
• Cimduo (lamivudine-tenofovir DF) plus Tivicay (dolutegravir)
OR
• For continuation of prior therapy

P & T Revisions

2024-02-19, 2023-01-31, 2022-01-27, 2021-02-03, 2020-01-22, 2019-12-10

References

1. Atripla Prescribing Information. Gilead Sciences, LLC. Foster City, CA. December 2021.

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Revision History

• 2024-02-19: 2024 Annual review, no changes to clinical criteria. Update references.
• 2023-01-31: Annual review - added FDA diagnosis criterion and minimum 30-day trial requirement for ST.
• 2022-01-27: Annual review - no changes.
• 2021-02-03: Removed drug name from continuation of therapy criterion.
• 2020-01-22: Annual review - updated references.
• 2019-12-10: Moving to Non-Specialty for 1/1/2020.

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