Health Net
Trogarzo (ibalizumab-uiyk)
Drugs for Infections : Drugs for Viral Infections
  • Step Therapy: Antiviral: HIV:
    ST Multiple Brands

  • Prior Authorization: Antiviral: HIV:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Antiviral: HIV:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of HIV Specialist;Infectious Disease Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Approved Indication Type(s) Included in Policy (HIV vs PrEP): HIV Only
    Restriction to use in combo with other ARVs: No
    Policy Required Patient Type: Naive vs. Treatment-Experienced: Treatment Experienced
    Documented Viral Load Assay Required for PA Renewals: No
    Supporting Documentation Requirements: 3 of Chart Notes;Medical Tests;Medication History
    Documented Diagnosis: Yes
    Restriction to Use For Active HIV Indication Only: Yes
    Restriction to Use For PrEP Indication Only: No

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