Certain HIV medication combinations may require prior authorization

Effective May 1, 2021, we will implement a new prior authorization requirement 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 new prior authorization requirement 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 necessary.

 

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 be initiated 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 www.CoverMyMeds.com). If you have questions, please call the Provider Service phone number on the member’s ID card.

 

1002-0321-PN-NE