Starting May 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new prior authorization for HIV medications to help ensure patients are not receiving therapeutic duplications when taking certain combinations. Providers and members expected to be impacted by this policy will receive advanced notice by mail.

 

In order for members to continue to receive coverage for the drug combination, providers must submit a separate prior authorization form for each drug and provide the medical necessity rationale for why the drug combination is clinically needed.

 

Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.

 

The duplicate therapy policy may trigger as a result of one of the following drug combinations:

Duplicate Name

Duplicate Description

Example

Integrase stand transfer inhibitors (INSTI)

Two drug products each containing a drug with an INSTI mechanism of action.

Isentress (raltegravir) and Dovato (dolutegravir/ lamivudine).

Non-nucleoside reverse transcriptase inhibitors (NNRTI)

Two drug products each containing a drug with an NNRTI mechanism of action.

Edurant (rilpivirine) and Symfi (efavirenz/lamivudine/TDF).

Protease inhibitors (PI)

Two drug products each containing a drug with a PI mechanism of action.

Prezcobix (darunavir/cobicistat) and Reyataz (atazanavir).

Nucleoside reverse transcriptase inhibitors (NRTI)

Two drug products that together result in four NRTI active ingredients.

Truvada (emtricitabine/TDF) and Biktarvy (bictegravir/ emtricitabine/TAF).

Boosters

Two drug products that result in a combination of the protease inhibitor boosters, ritonavir and cobicistat.

Prezcobix (darunavir/cobicistat) and Kaletra (lopinavir/ritonavir).


As a reminder, prior authorizations may be submitted via phone, fax, or online (through CoverMyMeds.com). If you have any questions regarding this policy, please contact your local provider network consultant.

 

1002-0321-PN-GA



Featured In:
March 2021 Anthem Provider News - Georgia