Cabotegravir — Blue Cross Blue Shield of Alabama

Initial criteria

• The requested PrEP agent is covered under the pharmacy benefit or has been approved through the coverage exception process
• The requested agent is being used for PrEP
• There is support that the requested PrEP agent is medically necessary
• The requested PrEP agent is ONE of the following: Tenofovir disoproxil fumarate and emtricitabine combination ingredient agent OR Tenofovir alafenamide and emtricitabine combination ingredient agent OR Cabotegravir
• The patient has increased risk for HIV infection
• The patient has recently tested negative for HIV

Approval duration

12 months