Rukobia (fostemsavir extended-release tablets) — Cigna

Initial criteria

• Patient is age ≥ 18 years; AND
• According to the prescriber, the patient is failing a current antiretroviral regimen for HIV; AND
• According to the prescriber, the patient has exhausted at least FOUR of the following antiretroviral classes defined as elimination of all antiretrovirals within a given class due to demonstrated or projected resistance to the agent(s) in that class OR due to significant intolerance (at least FOUR of a, b, c, d, e, or f): a) Nucleoside reverse transcriptase inhibitor; OR b) Non-nucleoside reverse transcriptase inhibitor; OR c) Protease inhibitor; OR d) Fusion inhibitor; OR e) Integrase strand transfer inhibitor; OR f) CCR5 antagonist; AND
• The medication will be taken in combination with an optimized antiviral background regimen including one or more other antiretroviral agents; AND
• The medication is prescribed by or in consultation with a physician who specializes in the treatment of HIV infection.

Reauthorization criteria

• Patient is currently receiving Rukobia; AND
• The medication is prescribed by or in consultation with a physician who specializes in the treatment of HIV infection.

Approval duration

initial: 6 months; reauthorization: 1 year