Long-Acting Injectable Antiretroviral Agents for Treatment of HIV

This policy covers long‑acting injectable antiretroviral agents for treatment of HIV‑1—primarily cabotegravir/rilpivirine (Cabenuva) for patients who are virologically suppressed on a stable antiretroviral regimen and lenacapavir (Sunlenca) for treatment‑experienced individuals with multidrug‑resistant HIV failing current therapy—when dose, frequency, and duration align with authoritative guidance. Major requirements and limitations include documented viral suppression (HIV‑1 RNA <50 copies/mL) and no prior virologic failure or baseline resistance for Cabenuva, exclusion of non‑FDA‑approved or unsupported off‑label uses as experimental/unproven, adherence to the member’s benefit plan and applicable state (Ohio) compendia/rules, and that initiation in treatment‑naive or viremic patients is not covered.

"Therapies proven effective for the relevant diagnosis or procedure are eligible for coverage."