CurrentColorado Rocky Mountain Health PlansPolicy 2026 P 1092-14

Selzentry® (maraviroc) - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new

Prior authorization policy for Selzentry (maraviroc) for UnitedHealthcare commercial plans, defining clinical criteria for approval, authorization duration, and additional clinical/billing rules.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySelzentry® (maraviroc) - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2026 P 1092-14

Change TypeAnnual review (no coverage changes)

Effective DateApr 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required; approval will be issued for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Annual review with no changes to coverage criteria (1/2026).

Effective date updated to 4/1/2026.

12Authorization duration

2Required approval criteria

CCR5Allowed viral tropism

Coverage Summary

Background: Selzentry (maraviroc) is a CCR5 co-receptor antagonist indicated in combination with other antiretroviral agents for treatment of CCR5-tropic HIV-1 in adults and pediatric patients weighing ≥2 kg. It is not recommended for dual/mixed- or CXCR4-tropic HIV-1. Tropism testing with a highly sensitive tropism assay is required. Coverage stance: covered_with_criteria. Scope summary: Prior authorization policy for Selzentry (maraviroc) for UnitedHealthcare commercial plans, defining clinical criteria for approval, authorization duration, and additional clinical/billing rules.

Authorization (Initial and Re-authorization)

Selzentry will be approved when ALL of the following criteria are met:

Patient has CCR5-tropic HIV-1 infection as confirmed by a highly sensitive tropism assay
Tropism testing with a highly sensitive tropism assay is required.
Patient is currently taking or will be prescribed an optimized background antiretroviral therapy regimen

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Prior authorization/notification is required. When the coverage criteria are met, approval will be issued for 12 months.

Documentation Required

Tropism testing documentation required

Documentation of CCR5-tropic status confirmed by a highly sensitive tropism assay must be provided to support approval.

Documentation Required

Optimized background regimen documentation

Provider must document that the patient is or will be prescribed an optimized background antiretroviral therapy regimen.

Billing Rule

Authorization duration

Authorization will be issued for 12 months.

Denial Risk

Ineligible tropism

Claims for patients with dual/mixed- or CXCR4-tropic HIV-1 will not meet coverage criteria and are at risk for denial.

Billing Rule

Automated approvals may apply

UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic per program-specific automated processes.

Clinical Evidence & Definitions

Evidence: Prescribing information referenced: Selzentry [Package Insert], ViiV Healthcare; September 2022. UnitedHealthcare program documentation and change history support the program number and effective date. The policy requires confirmation of CCR5-tropic HIV-1 using a highly sensitive tropism assay as part of the coverage criteria and documentation requirements. Authorization duration supported by program guidance is 12 months.

Definitions: Highly sensitive tropism assay — A laboratory assay used to determine HIV-1 co-receptor usage (CCR5 vs CXCR4 or dual/mixed) with high sensitivity.

Definitions: Optimized background antiretroviral therapy regimen — A combination of other antiretroviral agents selected to be appropriate and effective for the patient's HIV treatment regimen; patients must be currently taking or will be prescribed such an optimized background regimen as a coverage requirement.

Background

Selzentry ® (maraviroc) is a CCR5 co-receptor antagonist indicated in combination with other antiretroviral agents for the treatment of only CCR5-tropic human immunodeficiency virus type 1 (HIV-1) infection in adults and pediatric patients weighing at least 2 kg. Selzentry is not recommended in patients with dual/mixed- or CXCR4-tropic HIV-1. Tropism testing with a highly sensitive tropism assay is required for the appropriate use of Selzentry.