J1746, Injection, ibalizumab-uiyk, 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Provider attestation that the patient has multi-drug resistant HIV-1 infection (required for initial therapy)
- Provider confirmation/documentation that the patient has been prescribed an optimized background antiretroviral regimen containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility (required for initial and continuation therapy)
- For continuation therapy: documentation that the patient has previously received Trogarzo (ibalizumab-uiyk)
- For continuation therapy: provider confirmation/documentation that the patient has achieved a clinically significant viral response to Trogarzo therapy (e.g., documented viral load response)
Key Coverage Criteria
- Trogarzo (ibalizumab-uiyk) is proven and medically necessary for the treatment of multi-drug resistant human immunodeficiency virus (HIV) in patients who meet all of the following criteria:
- For initial therapy, all of the following:
- Diagnosis of HIV-1 infection
- Provider attestation that the patient has multi-drug resistant HIV-1 infection
- Provider confirms that the patient has been prescribed an optimized background antiretroviral regimen, containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility
- Trogarzo (ibalizumab-uiyk) initial and maintenance dosing is in accordance with the US Food and Drug Administration prescribing information
12 Active Policies
UHC-POL-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)
RX501.099, Ibalizumab-uiyk
BCBSIL-RX501.099, Ibalizumab-uiyk
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.099, Ibalizumab-uiyk
Related Codes
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