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Asset Publisher
Antiretroviral Quantity Limit Program Summary
Policy Number: PH-1199
This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
|
Effective Date |
Date of Origin |
|
10/1/2023 |
|
FDA APPROVED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|||||||||
|
|
||||||||||||||||||
|
|
Nevirapine Tab 200 MG |
200 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
|
Nevirapine Tab ER 24HR 100 MG |
100 MG |
900 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
|
Stavudine Cap 15 MG |
15 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
|
Stavudine Cap 20 MG |
20 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
|
Stavudine Cap 30 MG |
30 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
|
Stavudine Cap 40 MG |
40 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
|
Zidovudine Tab 300 MG |
300 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Aptivus |
Tipranavir Cap 250 MG |
250 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Atripla |
Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300 MG |
600-200-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Biktarvy |
Bictegravir-Emtricitabine-Tenofovir AF Tab |
30-120-15 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Biktarvy |
Bictegravir-Emtricitabine-Tenofovir AF Tab 50-200-25 MG |
50-200-25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Cimduo ; Temixys |
Lamivudine-Tenofovir Disoproxil Fumarate Tab 300-300 MG |
300-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Combivir |
Lamivudine-Zidovudine Tab 150-300 MG |
150-300 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Complera |
Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300 MG |
200-25-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Crixivan |
Indinavir Sulfate Cap 400 MG |
400 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Delstrigo |
Doravirine-Lamivudine-Tenofovir DF Tab 100-300-300 MG |
100-300-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Descovy |
Emtricitabine-Tenofovir Alafenamide Fumarate Tab |
120-15 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Descovy |
Emtricitabine-Tenofovir Alafenamide Fumarate Tab 200-25 MG |
200-25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Dovato |
Dolutegravir Sodium-Lamivudine Tab 50-300 MG (Base Eq) |
50-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Edurant |
Rilpivirine HCl Tab 25 MG (Base Equivalent) |
25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Emtriva |
Emtricitabine Caps 200 MG |
200 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Emtriva |
Emtricitabine Soln 10 MG/ML |
10 MG/ML |
680 |
mLs |
28 |
DAYS |
|
|
|
|||||||||
|
Epivir |
Lamivudine Oral Soln 10 MG/ML |
10 MG/ML |
960 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Epivir |
Lamivudine Tab 150 MG |
150 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Epivir |
Lamivudine Tab 300 MG |
300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Epzicom |
Abacavir Sulfate-Lamivudine Tab 600-300 MG |
600-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Evotaz |
Atazanavir Sulfate-Cobicistat Tab 300-150 MG (Base Equiv) |
300-150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Fuzeon |
Enfuvirtide For Inj 90 MG |
90 MG |
60 |
Vials |
30 |
DAYS |
|
|
|
|||||||||
|
Genvoya |
Elvitegrav-Cobic-Emtricitab-Tenofov AF Tab 150-150-200-10 MG |
150-150-200-10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Intelence |
Etravirine Tab 100 MG |
100 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Intelence |
Etravirine Tab 200 MG |
200 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Intelence |
Etravirine Tab 25 MG |
25 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Invirase |
Saquinavir Mesylate Tab 500 MG |
500 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Isentress |
Raltegravir Potassium Chew Tab 100 MG (Base Equiv) |
100 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Isentress |
Raltegravir Potassium Chew Tab 25 MG (Base Equiv) |
25 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Isentress |
Raltegravir Potassium Packet For Susp 100 MG (Base Equiv) |
100 MG |
60 |
Packets |
30 |
DAYS |
|
|
|
|||||||||
|
Isentress |
Raltegravir Potassium Tab 400 MG (Base Equiv) |
400 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Isentress hd |
Raltegravir Potassium Tab 600 MG (Base Equiv) |
600 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Juluca |
Dolutegravir Sodium-Rilpivirine HCl Tab 50-25 MG (Base Eq) |
50-25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Kaletra |
Lopinavir-Ritonavir Soln 400-100 MG/5ML (80-20 MG/ML) |
400-100 MG/5ML |
480 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Kaletra |
Lopinavir-Ritonavir Tab 100-25 MG |
100-25 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Kaletra |
Lopinavir-Ritonavir Tab 200-50 MG |
200-50 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Lexiva |
Fosamprenavir Calcium Susp 50 MG/ML (Base Equiv) |
50 MG/ML |
1800 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Lexiva |
Fosamprenavir Calcium Tab 700 MG (Base Equiv) |
700 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Norvir |
Ritonavir Oral Soln 80 MG/ML |
80 MG/ML |
480 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Norvir |
Ritonavir Powder Packet 100 MG |
100 MG |
360 |
Packets |
30 |
DAYS |
|
|
|
|||||||||
|
Norvir |
Ritonavir Tab 100 MG |
100 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Odefsey |
Emtricitabine-Rilpivirine-Tenofovir AF Tab 200-25-25 MG |
200-25-25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Pifeltro |
Doravirine Tab 100 MG |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Prezcobix |
Darunavir-Cobicistat Tab 800-150 MG |
800-150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Prezista |
Darunavir Oral Susp |
100 MG/ML |
400 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Prezista |
Darunavir Tab |
75 MG |
300 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Prezista |
Darunavir Tab |
150 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Prezista |
Darunavir Tab |
600 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Prezista |
Darunavir Tab |
800 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Retrovir |
Zidovudine Cap 100 MG |
100 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Retrovir |
Zidovudine Syrup 10 MG/ML |
50 MG/5ML |
1920 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Reyataz |
Atazanavir Sulfate Cap 150 MG (Base Equiv) |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Reyataz |
Atazanavir Sulfate Cap 200 MG (Base Equiv) |
200 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Reyataz |
Atazanavir Sulfate Cap 300 MG (Base Equiv) |
300 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Reyataz |
Atazanavir Sulfate Oral Powder Packet 50 MG (Base Equiv) |
50 MG |
240 |
Packets |
30 |
DAYS |
|
|
|
|||||||||
|
Rukobia |
Fostemsavir Tromethamine Tab ER 12HR 600 MG |
600 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Selzentry |
Maraviroc Oral Soln 20 MG/ML |
20 MG/ML |
1840 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Selzentry |
Maraviroc Tab 150 MG |
150 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Selzentry |
Maraviroc Tab 25 MG |
25 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Selzentry |
Maraviroc Tab 300 MG |
300 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Selzentry |
Maraviroc Tab 75 MG |
75 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Stribild |
Elvitegrav-Cobic-Emtricitab-TenofovDF Tab 150-150-200-300 MG |
150-150-200-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Sunlenca |
Lenacapavir Sodium Tab Therapy Pack |
300 MG |
4 |
Tablets |
365 |
DAYS |
|
|
|
|||||||||
|
Sunlenca |
Lenacapavir Sodium Tab Therapy Pack |
300 MG |
5 |
Tablets |
365 |
DAYS |
|
|
|
|||||||||
|
Sustiva |
Efavirenz Cap 200 MG |
200 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Sustiva |
Efavirenz Cap 50 MG |
50 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
|||||||||
|
Sustiva |
Efavirenz Tab 600 MG |
600 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Symfi |
Efavirenz-Lamivudine-Tenofovir DF Tab 600-300-300 MG |
600-300-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Symfi lo |
Efavirenz-Lamivudine-Tenofovir DF Tab 400-300-300 MG |
400-300-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Symtuza |
Darunavir-Cobic-Emtricitab-Tenofov AF Tab 800-150-200-10 MG |
800-150-200-10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Tivicay |
Dolutegravir Sodium Tab 10 MG (Base Equiv) |
10 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Tivicay |
Dolutegravir Sodium Tab 25 MG (Base Equiv) |
25 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Tivicay |
Dolutegravir Sodium Tab 50 MG (Base Equiv) |
50 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Tivicay pd |
Dolutegravir Sodium Tab for Oral Susp 5 MG (Base Equiv) |
5 MG |
360 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Triumeq |
Abacavir-Dolutegravir-Lamivudine Tab 600-50-300 MG |
600-50-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Triumeq pd |
Abacavir-Dolutegravir-Lamivudine Tab for Oral Sus |
60-5-30 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Trizivir |
Abacavir Sulfate-Lamivudine-Zidovudine Tab 300-150-300 MG |
300-150-300 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 100-150 MG |
100-150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 133-200 MG |
133-200 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 167-250 MG |
167-250 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG |
200-300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Tybost |
Cobicistat Tab 150 MG |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viracept |
Nelfinavir Mesylate Tab 250 MG |
250 MG |
270 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viracept |
Nelfinavir Mesylate Tab 625 MG |
625 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viramune |
Nevirapine Susp 50 MG/5ML |
50 MG/5ML |
1200 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Viramune xr |
Nevirapine Tab ER 24HR 400 MG |
400 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viread |
Tenofovir Disoproxil Fumarate Oral Powder 40 MG/GM |
40 MG/GM |
240 |
Grams |
30 |
DAYS |
|
|
|
|||||||||
|
Viread |
Tenofovir Disoproxil Fumarate Tab 150 MG |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viread |
Tenofovir Disoproxil Fumarate Tab 200 MG |
200 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viread |
Tenofovir Disoproxil Fumarate Tab 250 MG |
250 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Viread |
Tenofovir Disoproxil Fumarate Tab 300 MG |
300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
|
Ziagen |
Abacavir Sulfate Soln 20 MG/ML (Base Equiv) |
20 MG/ML |
960 |
mLs |
30 |
DAYS |
|
|
|
|||||||||
|
Ziagen |
Abacavir Sulfate Tab 300 MG (Base Equiv) |
300 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|||||||||
CLIENT SUMMARY – QUANTITY LIMITS
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
Nevirapine Tab 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Nevirapine Tab ER 24HR 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Stavudine Cap 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Stavudine Cap 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Stavudine Cap 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Stavudine Cap 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
|
Zidovudine Tab 300 MG |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Aptivus |
Tipranavir Cap 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Atripla |
Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300 MG |
600-200-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Biktarvy |
Bictegravir-Emtricitabine-Tenofovir AF Tab |
30-120-15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Biktarvy |
Bictegravir-Emtricitabine-Tenofovir AF Tab 50-200-25 MG |
50-200-25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Cimduo ; Temixys |
Lamivudine-Tenofovir Disoproxil Fumarate Tab 300-300 MG |
300-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Combivir |
Lamivudine-Zidovudine Tab 150-300 MG |
150-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Complera |
Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300 MG |
200-25-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Crixivan |
Indinavir Sulfate Cap 400 MG |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Delstrigo |
Doravirine-Lamivudine-Tenofovir DF Tab 100-300-300 MG |
100-300-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Descovy |
Emtricitabine-Tenofovir Alafenamide Fumarate Tab |
120-15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Descovy |
Emtricitabine-Tenofovir Alafenamide Fumarate Tab 200-25 MG |
200-25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Dovato |
Dolutegravir Sodium-Lamivudine Tab 50-300 MG (Base Eq) |
50-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Edurant |
Rilpivirine HCl Tab 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Emtriva |
Emtricitabine Caps 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Emtriva |
Emtricitabine Soln 10 MG/ML |
10 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Epivir |
Lamivudine Oral Soln 10 MG/ML |
10 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Epivir |
Lamivudine Tab 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Epivir |
Lamivudine Tab 300 MG |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Epzicom |
Abacavir Sulfate-Lamivudine Tab 600-300 MG |
600-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Evotaz |
Atazanavir Sulfate-Cobicistat Tab 300-150 MG (Base Equiv) |
300-150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Fuzeon |
Enfuvirtide For Inj 90 MG |
90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Genvoya |
Elvitegrav-Cobic-Emtricitab-Tenofov AF Tab 150-150-200-10 MG |
150-150-200-10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Intelence |
Etravirine Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Intelence |
Etravirine Tab 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Intelence |
Etravirine Tab 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Invirase |
Saquinavir Mesylate Tab 500 MG |
500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Isentress |
Raltegravir Potassium Chew Tab 100 MG (Base Equiv) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Isentress |
Raltegravir Potassium Chew Tab 25 MG (Base Equiv) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Isentress |
Raltegravir Potassium Packet For Susp 100 MG (Base Equiv) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Isentress |
Raltegravir Potassium Tab 400 MG (Base Equiv) |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Isentress hd |
Raltegravir Potassium Tab 600 MG (Base Equiv) |
600 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Juluca |
Dolutegravir Sodium-Rilpivirine HCl Tab 50-25 MG (Base Eq) |
50-25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Kaletra |
Lopinavir-Ritonavir Soln 400-100 MG/5ML (80-20 MG/ML) |
400-100 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Kaletra |
Lopinavir-Ritonavir Tab 100-25 MG |
100-25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Kaletra |
Lopinavir-Ritonavir Tab 200-50 MG |
200-50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Lexiva |
Fosamprenavir Calcium Susp 50 MG/ML (Base Equiv) |
50 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Lexiva |
Fosamprenavir Calcium Tab 700 MG (Base Equiv) |
700 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Norvir |
Ritonavir Oral Soln 80 MG/ML |
80 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Norvir |
Ritonavir Powder Packet 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Norvir |
Ritonavir Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Odefsey |
Emtricitabine-Rilpivirine-Tenofovir AF Tab 200-25-25 MG |
200-25-25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Pifeltro |
Doravirine Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Prezcobix |
Darunavir-Cobicistat Tab 800-150 MG |
800-150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Prezista |
Darunavir Oral Susp |
100 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Prezista |
Darunavir Tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Prezista |
Darunavir Tab |
600 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Prezista |
Darunavir Tab |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Prezista |
Darunavir Tab |
800 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Retrovir |
Zidovudine Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Retrovir |
Zidovudine Syrup 10 MG/ML |
50 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Reyataz |
Atazanavir Sulfate Cap 150 MG (Base Equiv) |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Reyataz |
Atazanavir Sulfate Cap 200 MG (Base Equiv) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Reyataz |
Atazanavir Sulfate Cap 300 MG (Base Equiv) |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Reyataz |
Atazanavir Sulfate Oral Powder Packet 50 MG (Base Equiv) |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Rukobia |
Fostemsavir Tromethamine Tab ER 12HR 600 MG |
600 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Selzentry |
Maraviroc Oral Soln 20 MG/ML |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Selzentry |
Maraviroc Tab 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Selzentry |
Maraviroc Tab 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Selzentry |
Maraviroc Tab 300 MG |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Selzentry |
Maraviroc Tab 75 MG |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Stribild |
Elvitegrav-Cobic-Emtricitab-TenofovDF Tab 150-150-200-300 MG |
150-150-200-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Sunlenca |
Lenacapavir Sodium Tab Therapy Pack |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Sunlenca |
Lenacapavir Sodium Tab Therapy Pack |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Sustiva |
Efavirenz Cap 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Sustiva |
Efavirenz Cap 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Sustiva |
Efavirenz Tab 600 MG |
600 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symfi |
Efavirenz-Lamivudine-Tenofovir DF Tab 600-300-300 MG |
600-300-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symfi lo |
Efavirenz-Lamivudine-Tenofovir DF Tab 400-300-300 MG |
400-300-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Symtuza |
Darunavir-Cobic-Emtricitab-Tenofov AF Tab 800-150-200-10 MG |
800-150-200-10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tivicay |
Dolutegravir Sodium Tab 10 MG (Base Equiv) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tivicay |
Dolutegravir Sodium Tab 25 MG (Base Equiv) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tivicay |
Dolutegravir Sodium Tab 50 MG (Base Equiv) |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tivicay pd |
Dolutegravir Sodium Tab for Oral Susp 5 MG (Base Equiv) |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Triumeq |
Abacavir-Dolutegravir-Lamivudine Tab 600-50-300 MG |
600-50-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Triumeq pd |
Abacavir-Dolutegravir-Lamivudine Tab for Oral Sus |
60-5-30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Trizivir |
Abacavir Sulfate-Lamivudine-Zidovudine Tab 300-150-300 MG |
300-150-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 100-150 MG |
100-150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 133-200 MG |
133-200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 167-250 MG |
167-250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Truvada |
Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG |
200-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tybost |
Cobicistat Tab 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viracept |
Nelfinavir Mesylate Tab 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viracept |
Nelfinavir Mesylate Tab 625 MG |
625 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viramune |
Nevirapine Susp 50 MG/5ML |
50 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viramune xr |
Nevirapine Tab ER 24HR 400 MG |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viread |
Tenofovir Disoproxil Fumarate Oral Powder 40 MG/GM |
40 MG/GM |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viread |
Tenofovir Disoproxil Fumarate Tab 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viread |
Tenofovir Disoproxil Fumarate Tab 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viread |
Tenofovir Disoproxil Fumarate Tab 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Viread |
Tenofovir Disoproxil Fumarate Tab 300 MG |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Ziagen |
Abacavir Sulfate Soln 20 MG/ML (Base Equiv) |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Ziagen |
Abacavir Sulfate Tab 300 MG (Base Equiv) |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
|
|
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
BCBSAL _ Commercial _ PS _ Antiretroviral Quantity Limit _ProgSum_ 10/1/2023