CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization form — rilpivirine (Edurant) for HIV-1

This document is a Washington state prior authorization request form used to request coverage of the antiretroviral rilpivirine (Edurant) for treatment of HIV-1; it is intended for prescribers submitting to the payer and applies to members needing prior authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization form — rilpivirine (Edurant) for HIV-1

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization by faxing the completed form with chart notes and labs to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursallow at least time for review

866-940-7328fax number to submit form

800-310-6826phone number for questions

6 monthslookback for prior Edurant use

35 kgminimum body weight check

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.

Coverage Criteria for Rilpivirine (Edurant)

Information required to evaluate medical necessity

Coverage assessment requires submission of ALL of the following information with the prior authorization request:

Required form elements: Completed member and provider information, medication details, diagnosis with ICD-10 code, and prior medication trials

From Sections A–D

Clinical criteria: Indicate whether request is new or continuation; if a continuation, document prior Edurant use within last 6 months; if ART-experienced, document virologic suppression for at least 6 months (HIV-1 RNA < 50 copies/mL) and provide current HIV-1 RNA value; confirm body weight >= 35 kg; list concomitant interacting medications (e.g., carbamazepine, dexamethasone > single dose, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifapentine, St John's Wort, proton pump inhibitors); identify other ART medications to be used in combination

From Clinical and Drug Specific Information

Documentation attachments: Attach chart notes, relevant laboratory results, and tests (including HIV-1 RNA) with the request

Required per form footer

Therapeutic rationale: Provide previous medication trial details (medication name, dates of therapy, reason for failure/discontinuation) and explain why preferred medications would not meet the patient's needs (refer to patient PDL)

Section D and E

The form explicitly asks whether rilpivirine (Edurant) will be used in combination with cabotegravir by providing a required yes/no response field. Providers must indicate Yes or No on the prior authorization form to document this combination therapy consideration.

The form does not provide a standalone list of items deemed “not medically necessary.” Instead, it requests specific clinical data to support medical necessity decisions—examples include current HIV-1 RNA value, documentation of virologic suppression when applicable, body weight, and a list of concomitant interacting medications. These data elements are required on the form to allow assessment of appropriateness rather than to enumerate explicit noncoverage conditions.

Diagnosis and Clinical Coding

Diagnosis codes (form field)ICD-10

ICD-10 CODE

Field for diagnosis code (exact code not provided in form)

Body weight requirement

Minimum body weight>= 35 kg

Form questionIs the patient's body weight greater than or equal to 35 kg? (yes/no)

PurposeUsed to confirm eligibility for rilpivirine (Edurant) therapy per prior authorization form

Virologic suppression

Virologic suppression thresholdHIV-1 RNA < 50 copies/mL

Required durationFor at least 6 months

Form question

Definitions

Virologic suppression (form definition)

Definition used on formVirologic suppression = HIV-1 RNA < 50 copies/mL for at least 6 months

Form fieldQuestion asked when patient is ART-experienced to document suppression duration and current HIV-1 RNA value

Supporting data to submitCurrent HIV-1 RNA (copies/mL) requested in form field 5

Provider Submission Requirements & Actions

Prior Authorization

Prior Authorization Required

Prior authorization must be requested using the Edurant (rilpivirine) Washington Prior Authorization Request Form and faxed to 866-940-7328. Allow at least 24 hours for review. If you have questions, call 800-310-6826. Complete the entire form (all pages) to avoid delays.

Fax: 866-940-7328
Phone for questions: 800-310-6826
Allow ≥ 24 hours for review

Documentation Required

Form Completion — Required Fields

Complete all required sections of the form: member information (including member ID, DOB, contact, allergies, and primary insurance), provider information (including NPI, specialty, and contact/fax), medication details (name, strength, directions, quantity), diagnosis with ICD-10 code, and previous medication trials (names, dates, reasons for failure/discontinuation). Indicate whether the request is new or a continuation and provide the therapy start date if continuation.

Background

Rilpivirine (Edurant) is an antiretroviral agent indicated for the treatment of HIV-1. The prior authorization form collects information about concurrent antiretroviral therapy (which other ART medications will be used in combination with rilpivirine), whether the request is a continuation, prior rilpivirine use within the last 6 months, ART experience and virologic suppression status, current HIV-1 RNA value, body weight (check for >= 35 kg), and any concomitant medications with potential interactions.

Documentation Required

Required Documentation — Chart Notes, Labs & Tests

Chart notes, relevant laboratory results (including HIV-1 RNA), and other tests must be submitted with the prior authorization request. Required clinical/drug-specific information includes: whether this is continuation of therapy and prior use of rilpivirine within 6 months, ART regimen details (which other antiretroviral(s) will be used in combination), whether patient is ART-experienced and virologic suppression status, current HIV-1 RNA value, body weight (≥ 35 kg), and any concomitant medications that interact with rilpivirine (e.g., carbamazepine, phenytoin, rifampin, St John's Wort, proton pump inhibitors).

Include chart notes and labs with request
Include HIV-1 RNA value (copies/mL)
Confirm body weight ≥ 35 kg
Document ART regimen and whether used in combination with cabotegravir
List concomitant medications (carbamazepine, phenytoin, phenobarbital, rifampin, rifapentine, St John's Wort, proton pump inhibitors, dexamethasone, oxcarbazepine)