Trogarzo®
Drug - Trogarzo® (ibalizumab-uiyk) [Theratechnologies Inc.]
December 2018
Therapeutic area - Antiretroviral - HIV
Initial approval criteria
- Patient is at least 18 years old AND
- Patient has heavily treated multidrug resistant disease (including failure of at least one NRTI, NNRTI, and PI) AND
- Used in combination with antiretroviral therapy (ART) AND
- Patient is currently failing on their current antiretroviral regimen
- Initial approval is for 6 months
Renewal criteria
- Patient continues to meet initial criteria AND
- Disease response as indicated by a decrease in viral load AND
- Absence of unacceptable toxicity from the drug
- Renewal approval is for 6 months
Quantity limits
- Loading dose = 2000 mg (10 vials or 13.3mL)
- Maintenance dose = 800 mg (4 vials or 5.32 mL) every 2 weeks
Billing for Trogarzo
Trogarzo must be billed as a medical claim.
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411