Truvada (emtricitabine and tenofovir DF) and Descovy (emtricitabine and tenofovir alafenamide) Medicaid Fee-for-Service

Truvada (emtricitabine/ tenofovir disoproxil fumarate) is a medication used for Post-Exposure Prophylaxis, Pre-Exposure Prophylaxis and treatment for HIV-positive individuals. Descovy (emtricitabine and tenofovir alafenamide) is also used for Pre-Exposure Prophylaxis and treatment for HIV-positive individuals.

Post Exposure Prophylaxis (PEP)

PEP (Truvada plus Raltegravir) is prescribed for 28 days.  A 'stat pack' for 3-7 days is given in the emergency department and prescriptions are given for the remainder of the days.

  • PEP is a medical emergency and does not need Prior Approval.  A prescription for 28 days or less will have an 'auto bypass' in the Medicaid fee for service system.
  • If for some reason this does not occur you can call Magellan at 877-309-9493 and tell them the prescription is for PEP and this should resolve any issue.

Pre- Exposure Prophylaxis (PrEP)

Pre-Exposure Prophylaxis consists of taking either Truvada or Descovy (excluding individuals at risk from receptive vaginal sex) once daily by an HIV negative person to remain HIV negative.

  • Initial fill does not require pre-authorization.  For subsequent fills the patient must have an HIV negative test documented in within the last 90 days. If testing can be confirmed, via the patients’ medical history, the subsequent claims should “auto bypass” and not require pre-authorization. If testing cannot be confirmed pre-authorization will be required to confirm the patient is HIV negative.

HIV Treatment

A person new to the Medicaid system:

  • It is beneficial to fill out the pre-authorization form for a first time Medicaid fee for service patient. This will provide the HIV diagnosis and antiretroviral history that is needed to approve the medications.
  • Absence of evidence of covered diagnosis or antiretroviral therapy in patient's claims history will require prescriber involvement.
  • Once the system can detect the necessary medical data in the patient's history an "auto bypass" may be able to be achieved.

Medicaid Fee for Service (FFS)

Medicaid Managed Care

  • For information on a specific Medicaid managed care health plan’s coverage of PEP or PrEP visit the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center
  • A quick survey of the plans indicate that PA is not required for PEP or PrEP however for the most up to date coverage criteria contact the Managed Care plan directly. See the website in the bullet above for plan contact information.