tenofovir disoproxil fumarate and emtricitabine — Blue Cross Blue Shield of Kansas

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: (A) Tenofovir disoproxil fumarate and emtricitabine combination ingredient agent OR (B) Tenofovir alafenamide and emtricitabine combination ingredient agent
• The patient has increased risk for HIV infection
• The patient has recently tested negative for HIV

Approval duration

12 months