Rukobia (fostemsavir extended-release tablets) — Cigna
Human immunodeficiency virus-1 (HIV-1) infection
Initial criteria
- Patient is age ≥ 18 years; AND
- Diagnosis of HIV-1 infection; AND
- Patient is heavily treatment-experienced with multidrug-resistant HIV-1 infection; AND
- Rukobia will be used in combination with an optimized background regimen including one or more other antiretroviral agents; AND
- Documentation that the patient has failed, is intolerant to, or has resistance to other available antiretroviral agents per guidelines
Reauthorization criteria
- Medication will continue to be taken in combination with an optimized antiviral background regimen including one or more other antiretroviral agents; AND
- Patient has responded to a Rukobia-containing regimen, as determined by the prescriber (examples of a response include HIV RNA < 40 cells/mm³, HIV-1 RNA ≥ 0.5 log reduction from baseline in viral load, improvement or stabilization of CD4 T-cell count)
Approval duration
12 months