CurrentCignaPolicy N/A

Cabenuva (cabotegravir/rilpivirine) prior authorization

This document is a Cigna prior-authorization request form governing coverage review for Cabenuva (cabotegravir/rilpivirine) injections for patients with HIV; it directs what information providers must supply to obtain coverage and where the medication will be obtained/ administered.

Policy Summary

PayerCigna

PolicyCabenuva (cabotegravir/rilpivirine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of weight, prior ART (>=3 months or 1-month Vocabria lead-in), and HIV-1 RNA <50 copies/mL.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

35 kgweight threshold

HIV-1 RNA <50viral suppression

Accredopreferred specialty pharmacy

Coverage Criteria for Cabenuva

New start

Covered when ALL of the following are met

New start criteria: Patient weight is documented and is >= 35 kg (or weight documented if <35 kg); documentation that prior to initiating Cabenuva the patient either completed a 1-month Vocabria (cabotegravir tablets) lead-in or was treated with a stable antiretroviral regimen for >= 3 months; documentation that the patient has HIV-1 RNA < 50 copies/mL (viral suppression); medication is prescribed by or in consultation with a physician who specializes in HIV when indicated; required supportive documentation (chart notes, laboratory tests, claims records, or other medical records) is attached to the request.>= 35 kg; HIV-1 RNA < 50 copies/mL

Each item requires attachment of supporting documentation (chart notes, lab results, claims records). Requests lacking required documentation may be denied.

Continuation of therapy

Covered when ALL of the following are met

Continuation criteria:

Policy Summary

PayerCigna

PolicyCabenuva (cabotegravir/rilpivirine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of weight, prior ART (>=3 months or 1-month Vocabria lead-in), and HIV-1 RNA <50 copies/mL.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medication, Diagnosis, and Threshold Coding

Requested medication strengthsmixed

400 mg/2 mL-600 mg/2 mL	Cabenuva suspension strength option listed on form
600 mg/3 mL-900 mg/3 mL	Cabenuva suspension strength option listed on form

Diagnosis (examples)ICD-10

B20	Human Immunodeficiency Virus (HIV)-1 infection (ICD-10) — implied selection on diagnosis section

inv-07: Weight threshold

Weight threshold>= 35 kg (form asks: 35 kg or more)

If <35 kgForm includes option for 34 kg or less; attach documentation and rationale

Documentation requirementWeight must be documented on the prior authorization form for new starts

inv-08: Viral suppression requirement

Viral suppression requirementHIV-1 RNA < 50 copies/mL

Applies toNew starts and continuations (form queries suppression for both)

Documentation requiredAttach lab results or chart notes showing HIV-1 RNA <50 copies/mL or request may be denied

What Providers Must Submit

Prior Authorization

Prior Authorization Required

Prior authorization required. Requests for Cabenuva require prior authorization and must include the clinical evidence described below. Incomplete submissions may delay review or result in denial.

Prior authorization is required for new starts and continuations.
If urgent, call Cigna to request expedited review; standard response time is 5 business days.

Documentation Required

Lead-in / Prior ART Documentation

Lead-in / prior antiretroviral therapy requirement for new starts. For patients initiating Cabenuva, documentation must show either a 1-month oral Vocabria (cabotegravir tablets) lead-in OR that the patient was on a stable antiretroviral regimen for ≥3 months prior to starting Cabenuva.

Documented 1-month Vocabria (cabotegravir) lead-in OR ≥3 months continuous prior ART before first Cabenuva injection.
Patient weight must be documented (e.g., ≥35 kg or <35 kg) for dosing considerations.
Cabenuva must be prescribed by or in consultation with a clinician experienced in HIV treatment (indicate specialty).

Documentation Required

Supportive Documentation Required

Required supportive documentation — attach with the PA request. Clinical documentation must be attached (chart notes, laboratory results, and/or claims) to support the clinical criteria. Requests lacking required documentation may be denied.

Evidence of prior ART duration (chart notes, claims, medication history) showing ≥3 months continuous therapy if not using Vocabria lead-in.
If using Vocabria lead-in, provide documentation of the 1-month oral lead-in period with dates and adherence notes.
HIV-1 RNA (viral load) demonstrating <50 copies/mL prior to first injection (new starts) and for continuations when requested.
Weight documentation (e.g., clinic measurement) for new starts.
Provider specialty or consultation note if prescribed by a non-HIV specialist.
Complete all asterisked patient and provider demographic fields on the PA form — Cigna cannot respond via fax unless these mandatory fields are filled.

Background

Cabenuva is a long-acting injectable regimen of cabotegravir and rilpivirine used for treatment of HIV-1. This prior-authorization form is designed to confirm appropriate patient selection and safe initiation or continuation by collecting key clinical information: patient weight (the form queries 35 kg or more), documentation of prior antiretroviral treatment or a 1-month Vocabria oral lead-in, and laboratory evidence of viral suppression (HIV-1 RNA < 50 copies/mL). The form requires that medical documentation (chart notes, lab results, claims records, etc.) be attached to support the responses; without these attachments, coverage review may be delayed or denied.

OpenPayer

Cabenuva (cabotegravir/rilpivirine) prior authorization

Coverage Criteria for Cabenuva

Medication, Diagnosis, and Threshold Coding

What Providers Must Submit

Background

Key Definitions