Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Agenerase amprenavir 15 mg/mL Solution   Not Applicable Agenerase amprenavir 50 mg capsule   Not Applicable Aptivus tipranavir 250 mg capsule   Not Applicable ATRIPLA efavirenz-emtricitabin-tenofov 600-200-300 mg tablet   Not Applicable Combivir lamivudine-zidovudine 150-300 mg tablet   Not Applicable Complera emtricitab-rilpivirine-tenofov 200-25-300 mg tablet   $$$$ Crixivan indinavir 100 mg capsule; 333 mg capsule; 200 mg capsule; 400 mg capsule   Not Applicable Edurant rilpivirine 25 mg tablet   Not Applicable Emtriva emtricitabine 10 mg/mL Solution   Not Applicable Emtriva emtricitabine 200 mg capsule   Not Applicable Epivir lamivudine 10 mg/mL Solution   Not Applicable Epivir lamivudine 300 mg tablet; 150 mg tablet   Not Applicable Epzicom abacavir-lamivudine 600-300 mg tablet   Not Applicable Fuzeon enfuvirtide 90 mg Kit   $$$$$+ Fuzeon enfuvirtide 90 mg Recon Soln   $$$$$+ Intelence etravirine 25 mg tablet; 200 mg tablet; 100 mg tablet   Not Applicable Invirase saquinavir mesylate 200 mg capsule   Not Applicable Invirase saquinavir mesylate 500 mg tablet   Not Applicable Isentress raltegravir 400 mg tablet   Not Applicable Kaletra lopinavir-ritonavir 100-25 mg tablet; 200-50 mg tablet   Not Applicable Kaletra lopinavir-ritonavir 133.3-33.3 mg capsule   Not Applicable Kaletra lopinavir-ritonavir 400-100 mg/5 mL Solution   Not Applicable Lexiva fosamprenavir 50 mg/mL Suspension   Not Applicable Lexiva fosamprenavir 700 mg tablet   Not Applicable Norvir ritonavir 100 mg capsule   Not Applicable Norvir ritonavir 100 mg tablet   Not Applicable Norvir ritonavir 80 mg/mL Solution   Not Applicable Prezista darunavir 100 mg/ml suspension   Not Applicable Prezista darunavir 150 mg tablet   Not Applicable Prezista darunavir 75 mg tablet; 400 mg tablet; 600 mg tablet; 300 mg tablet   Not Applicable Prezista darunavir 800 mg tablet   Not Applicable Retrovir zidovudine 10 mg/mL Solution   Not Applicable Retrovir zidovudine 10 mg/mL Syrup   Not Applicable Retrovir zidovudine 100 mg capsule   Not Applicable Retrovir zidovudine 300 mg tablet   Not Applicable Reyataz atazanavir 300 mg capsule; 100 mg capsule; 150 mg capsule; 200 mg capsule   Not Applicable Selzentry maraviroc 150 mg tablet; 300 mg tablet   Not Applicable Stribild elvitegr-cobicist-emtric-tenof 150-150-200-300 mg tablet   Not Applicable Sustiva efavirenz 200 mg capsule; 50 mg capsule; 100 mg capsule   Not Applicable Sustiva efavirenz 600 mg tablet   Not Applicable Trizivir abacavir-lamivudine-zidovudine 300-150-300 mg tablet   Not Applicable Truvada emtricitabine-tenofovir 200-300 mg tablet   Not Applicable Videx 2 gram Pediatric didanosine 10 mg/mL (Final) Recon Soln   Not Applicable Videx EC didanosine 250 mg capsule,delayed release(DR/EC); 125 mg capsule,delayed release(DR/EC); 200 mg capsule,delayed release(DR/EC); 400 mg capsule,delayed release(DR/EC)   Not Applicable Viracept nelfinavir 250 mg tablet; 625 mg tablet   Not Applicable Viramune nevirapine 200 mg tablet   Not Applicable Viramune nevirapine 50 mg/5 mL Suspension   Not Applicable Viramune XR nevirapine 400 mg tablet extended release 24 hr   Not Applicable Viread tenofovir disoproxil fumarate 150 mg tablet; 200 mg tablet; 250 mg tablet; 300 mg tablet   Not Applicable Viread tenofovir disoproxil fumarate 40 mg/scoop (40 mg/gram) Powder   Not Applicable Zerit stavudine 1 mg/mL Recon Soln   Not Applicable Zerit stavudine 15 mg capsule; 30 mg capsule; 20 mg capsule; 40 mg capsule   Not Applicable Ziagen abacavir 20 mg/mL Solution   Not Applicable Ziagen abacavir 300 mg tablet   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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