Descovy (emtricitabine/tenofovir alafenamide) prior authorization
Customize your policy alerts
Sign up for all mediviewcurative policy alerts
Know when mediviewcurative releases new policies or updates existing guidance.
Monitor payer policy activity
Defines prior authorization requirements for Descovy (emtricitabine/tenofovir alafenamide) for HIV pre-exposure prophylaxis (PrEP) and HIV treatment for members of Curative Health Plan (operating as Curative). Applies to requests for Descovy under the payer's drug coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria for Descovy
Initial Therapy — Covered when ALL of the following are met for the relevant indication
Covered when ALL of the following are met for the relevant indication
Indication must be consistent with PrEP
Either prior inadequate response to TDF or contraindication/intolerance fulfills the step therapy requirement
Continued Therapy — Covered when ALL of the following are met for the relevant indication
Covered when ALL of the following are met for the relevant indication
Maintains PrEP status
Continuation requires same step therapy condition as initial treatment
Requests will be approved only when the medication is being used for an FDA‑approved indication and all applicable policy criteria are met. Requests where the medication is not being used for an FDA‑approved indication will not meet approval criteria.
Drug and Billing Codes
| NDC | Descovy (emtricitabine/tenofovir alafenamide fumarate (TAF)) |
Provider Requirements and Operational Actions
Prior authorization required for Descovy
Prior authorization is required for Descovy (emtricitabine/tenofovir alafenamide) and will be approved when the medication is being used for an FDA‑approved indication and the applicable coverage criteria for PrEP or HIV treatment are met.
Step therapy: prior TDF trial or documented intolerance
For the HIV treatment indication, approval requires documentation that the patient has tried and had an inadequate response to emtricitabine/tenofovir disoproxil fumarate (TDF, Truvada) or has an intolerance or FDA‑labeled contraindication to TDF.
- Must show prior trial with inadequate response to TDF (emtricitabine/tenofovir disoproxil fumarate) OR
- Document an intolerance or FDA‑labeled contraindication to TDF
Required chart documentation of HIV status and indication
Include chart notes and/or prescriber documentation that indicate whether the patient has HIV (for treatment) or does not have HIV and is using Descovy for PrEP; timing requirements differ for initial versus continued therapy.
- Initial HIV treatment: diagnosis documented within past 180 days
- Continued therapy (HIV treatment): diagnosis documented within past 12 months
- PrEP (initial): documentation indicating patient does not have HIV
- PrEP (continued): documentation within past 12 months indicating patient does not have HIV
Missing indication or documentation may result in denial
Denial is likely if the requested medication is not being used for an FDA‑approved indication or if required documentation (e.g., chart notes showing HIV status or PrEP use) is not provided.
Background
Descovy (emtricitabine/tenofovir alafenamide) is authorized for use as HIV pre‑exposure prophylaxis (PrEP) in patients without HIV and as part of antiretroviral therapy for patients with a documented diagnosis of HIV. For PrEP, approval is contingent on chart notes or prescriber documentation that do not indicate the patient has HIV. For HIV treatment, approval requires a documented HIV diagnosis within the specified timeframe and either a prior inadequate response to tenofovir disoproxil fumarate (TDF/Truvada) or an intolerance/FDA‑labeled contraindication to TDF.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.