| Anthem Blue Cross (HMO, PPO, EPO) |
| Rukobia (fostemsavir) |
| Drugs for Infections : Drugs for Viral Infections |
- Step Therapy Applies
- Quantity Limit: 2 tablets per 1 day(s).
- Antiviral: HIV:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Approved Indication Type(s) Included in Policy (HIV vs PrEP): HIV Only
Restriction to use in combo with other ARVs: Yes
Policy Required Patient Type: Naive vs. Treatment-Experienced: Treatment Experienced
Documented Viral Load Assay Required for PA Renewals: No
Documented Diagnosis: Yes
Restriction to Use For Active HIV Indication Only: Yes
Restriction to Use For PrEP Indication Only: No
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on Quantity drug coverage click HERE; Split Fill;- Prior Authorization: Antiviral: HIV:
Documented Diagnosis: Yes
Duration: 1 year(s)
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