| Anthem Blue Cross (HMO, PPO, EPO) |
| Cabenuva (cabotegravir-rilpivirine) |
| Drugs for Infections : Drugs for Viral Infections |
- Antiviral: HIV:
Duration: 1 year(s)
Medical Test Required: Yes
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: No
Policy Required Patient Type: Naive vs. Treatment-Experienced: Treatment Experienced
Documented Viral Load Assay Required for PA Renewals: No
Supporting Documentation Requirements: Medical Tests
Documented Diagnosis: Yes
Restriction to Use For Active HIV Indication Only: Yes
Restriction to Use For PrEP Indication Only: No
- Quantity Limit: 1 kit per 28 day(s).
- Prior Authorization: Antiviral: HIV:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
|