HIV medication coverage and prior authorization FAQ
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This document explains Maryland Physicians Care (MPC) coverage policies, preferred agents, prior authorization processes, copays, pediatric exceptions, and emergency fill allowances for HIV-related medications for MPC members.
No material clinical or coverage changes in this revision.
Coverage summary and scope
General coverage summary
Coverage highlights and exceptions
explicit pediatric PA exemption per MPC FAQ
PrEP-specific coverage
Preferred agents may follow posted PA rules
cost sharing
For pediatric members (<21 years), MPC does not require prior authorization for any HIV medications; all HIV medications are covered for this age group. The policy does not list any other explicit exclusions for pediatric members.
No additional coverage details are specified in this document beyond the pediatric prior authorization exemption and the general coverage statements provided elsewhere in the FAQ.
Prior authorization, preferred agents, and submission instructions
Prior authorization rules and pediatric PA exemption
No prior authorization is required for members under 21 for any HIV medications; both preferred and non-preferred agents are covered without PA. For members aged 21 and older, non-preferred agents may require prior authorization per MPC processes and posted requirements.
- Pediatric exemption: All HIV medications for members <21 are covered without prior authorization per MPC FAQ.
- Adults (≥21): Follow MPC website and PA processes for non-preferred agents; preferred agents may follow different posted rules.
Where to find preferred agents and step/PA rules
MPC posts its preferred HIV medications list and non-preferred prior authorization requirements on the MPC website under the HIV-Carve-in Benefit Information section. Preferred single‑pill complete-regimen agents identified by MPC are Biktarvy, Symfi, and Symfi Lo.
- Location: MPC Website → HIV-Carve-in Benefit Information for preferred and non-preferred PA rules.
- Preferred single‑pill complete-regimen agents: Biktarvy; Symfi; Symfi Lo.
How to submit prior authorization and required documentation
Retrieve the authorization form from the MPC website and submit it with clinical documentation per MPC instructions: fax most PA requests to 833-896-0656 or call the MPC Pharmacy PA Department at 888-258-8250. For Trogarzo and Fuzeon, fax requests to 1-800-953-8856 for review by the Pharmacy Medical Department.
- Form: Obtain prior authorization form from MPC Website (HIV-Carve-in Benefit Information).
- Submit (most drugs): Fax to 833-896-0656 or call 888-258-8250.
- Trogarzo & Fuzeon: Fax to 1-800-953-8856 for Pharmacy Medical Department review.
Required clinical documentation and denial risk
Clinical documentation must accompany any prior authorization request for HIV medications; lack of supporting clinical documentation may result in denial of the PA request.
- Include relevant clinical information to support medical necessity with the authorization form.
- Denial risk: Requests submitted without required clinical documentation are subject to denial.
Policy background and scope notes
This FAQ explains administrative and coverage information for HIV medications under the MPC HIV Carve-In benefit. It specifically notes that pediatric members under 21 have an exemption from prior authorization and confirms coverage of HIV medications for that population; use the MPC website and associated sections of the FAQ for details on preferred agents, prior authorization processes for adult members, and submission instructions.
Key definitions used in this policy
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