CurrentmhnPolicy CP.PMN.235

Emtricitabine/Tenofovir Alafenamide (Descovy) coverage

Defines medical necessity and prior authorization criteria for Descovy (emtricitabine/tenofovir alafenamide) for treatment of HIV-1 and for HIV pre-exposure prophylaxis (PrEP) across specified Centene-affiliated lines of business.

Policy Summary

Payermhn

PolicyEmtricitabine/Tenofovir Alafenamide (Descovy) coverage

Policy CodePolicy CP.PMN.235

Change TypeNo material changes

Effective DateJun 1, 2020

Next Review Date

Key ActionProvider must submit documentation (office notes, labs, or other clinical information) showing the member meets all approval criteria for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2FDA-indications

14/17/25/35Weight thresholds

12 monthsApproval duration

2Tablet strengths

State-specificState provisions

Coverage Criteria for Descovy (Emtricitabine/Tenofovir Alafenamide)

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.

Initial Approval - HIV-1 Infection

Covered when ALL of the following are met:

HIV-1 Initial Therapy

Diagnosis of HIV-1 infection;
Descovy is prescribed in combination with other antiretroviral agents for the treatment of HIV-1 infection;
Member weighs ≥ 14 kg;
If treatment-naïve and member weighs ≥ 17 kg, member must instead use emtricitabine/tenofovir disoproxil fumarate (generic Truvada) unless contraindicated, clinically significant adverse effects are experienced, or member has bone/renal co-morbidities or risk factors (see Appendix D).
Do not flatten the step therapy exception
Dose does not exceed one of the following based on weight: - Weight 14 kg to < 25 kg: 120/15 mg (1 tablet) per day; - Weight ≥ 25 kg: 200/25 mg (1 tablet) per day.

Initial Approval - PrEP

Covered when ALL of the following are met:

PrEP Initial Therapy

Member is HIV-negative and has no signs or symptoms of acute HIV infection;
Member is considered at risk for acquiring HIV and meets one of the following: - Engaging in sexual activity with a HIV-1 infected partner; - Engaging in sexual activity and one or more of: inconsistent or no condom use; diagnosis of sexually transmitted infections; exchange of sex for commodities; incarceration; not in a monogamous partnership; partner of unknown HIV status with any of the preceding risk factors; - Use of illicit injection drugs;
Member weighs ≥ 35 kg;
Descovy is not prescribed concurrently with any other antiretroviral medications, including other agents for PrEP (e.g., Apretude, Yeztugo, emtricitabine/tenofovir disoproxil fumarate);

Continued Therapy

Covered when ALL of the following are met:

Continued Therapy Criteria

Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Descovy for a covered indication and has received this medication for at least 30 days;
Member is responding positively to therapy;
If request is for PrEP, Descovy is not prescribed concurrently with any other antiretroviral medications, including other agents for PrEP (e.g., Apretude, Yeztugo, emtricitabine/tenofovir disoproxil fumarate);
If request is for a dose increase, the new dose does not exceed: a) for treatment of HIV-1 infection in a member weighing 14 kg to < 25 kg: 120/15 mg (1 tablet) per day; b) for all other requests: 200/25 mg (1 tablet) per day.

Non–FDA approved indications that are not specifically addressed in this policy are not authorized for coverage unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with applicable off‑label use policies or the member’s evidence of coverage. Relevant off‑label policies include CP.CPA.09 (commercial), HIM.PA.154 (health insurance marketplace/ICHRA), and CP.PMN.53 (Medicaid).

For HIV pre‑exposure prophylaxis (PrEP), Descovy must not be prescribed concurrently with any other antiretroviral medication intended for PrEP. This concurrent‑use prohibition was added in the 2Q 2026 annual review and applies when evaluating initial and continuation PrEP requests.

Descovy is contraindicated for use as PrEP in individuals with unknown or positive HIV‑1 status. Providers must confirm and document a negative HIV‑1 status with no signs or symptoms of acute infection before initiating Descovy for PrEP; use in persons with undiagnosed or confirmed HIV‑1 infection is not appropriate.

Prior Authorization, Step Therapy, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. Providers must submit documentation (such as office chart notes, laboratory results, or other clinical information) that supports the member meets all approval criteria for use of Descovy (emtricitabine/tenofovir alafenamide). Failure to provide complete documentation may result in denial or delays of prior authorization.

Required documentation: office notes, labs, other clinical information supporting diagnosis, weight, dosing, and indication (treatment of HIV-1 vs PrEP).
For PrEP requests: documentation of HIV-negative status and absence of acute HIV infection, risk factors for acquisition, member weight, and confirmation that Descovy will not be prescribed concurrently with other antiretrovirals for PrEP.

Step Therapy

Step Therapy Requirement for Treatment‑Naïve Members

A step therapy requirement applies for treatment‑naïve members weighing ≥17 kg: emtricitabine/tenofovir disoproxil fumarate (generic Truvada) must be used first unless it is contraindicated, causes clinically significant adverse effects, or the member has bone/renal comorbidities or risk factors that warrant use of Descovy.

Illinois HIM: step therapy bypass added per IL HB 5395 (effective 1/1/2026) — requests under Illinois HIM do not require the step.
Nevada: medical management techniques, including quantity management beyond step therapy, are not allowed per state-specific note.

Note

Prior Authorization and Step Therapy Updates (History)

Step therapy and prior authorization requirements have been updated over time. Historical policy changes include extension of pediatric weight criteria, addition/removal of redirection to generic Truvada for PrEP, and jurisdiction-specific bypasses or disclaimers.

2Q 2022: pediatric weight extension to ≥14 kg and addition of lower‑strength tablet.
01.07.25–02.25: removed redirection to generic Truvada per USPSTF PrEP recommendation (historical change).
02.14.25–05.25: added step therapy bypass for IL HIM per IL HB 5395.
2Q 2026: For PrEP, added requirement that Descovy is not prescribed concurrently with any other antiretroviral medications for PrEP; references reviewed and updated.

Documentation Required

Concurrent PrEP Antiretroviral Prescribing — Do Not Co‑prescribe

Descovy must not be prescribed concurrently with any other antiretroviral medications for the indication of pre‑exposure prophylaxis (PrEP). Examples include long‑acting cabotegravir (Apretude), Yeztugo, or emtricitabine/tenofovir disoproxil fumarate. Ensure the prior authorization documentation confirms no concurrent PrEP antiretrovirals are being used.

Applies to PrEP only; treatment of HIV-1 infection requires Descovy be used in combination with other antiretroviral agents as appropriate.
Prior authorization reviewers will verify medication reconciliation and prescription history to confirm no concurrent PrEP agents.

Definitions and Product Details

TAF vs TDF

TAF (in Descovy) vs TDFTenofovir alafenamide (TAF), the prodrug in Descovy, is associated with fewer bone and renal toxicities than tenofovir disoproxil fumarate (TDF)

TDF clinical differencesTDF is associated with lower lipid levels compared with TAF

Clinical guidanceSelection between TAF and TDF should consider safety, cost, and accessibility as per DHHS guidelines

PrEP exclusion

PrEP population exclusionDescovy is not indicated for PrEP in individuals at risk from receptive vaginal sex because effectiveness has not been evaluated in that population

HIV testing requirementIndividuals must have a negative HIV-1 test immediately prior to initiating Descovy for PrEP

Concurrent antiretroviralsDescovy must not be prescribed concurrently with any other antiretroviral medications for PrEP

Product availability

Available tablet strengths200 mg emtricitabine / 25 mg tenofovir alafenamide

Lower-strength tablet120 mg emtricitabine / 15 mg tenofovir alafenamide

Dosing correspondence120/15 mg tablet used for pediatric patients 14 kg to <25 kg; 200/25 mg used for ≥25 kg and for PrEP

OpenPayer

Emtricitabine/Tenofovir Alafenamide (Descovy) coverage

Coverage Criteria for Descovy (Emtricitabine/Tenofovir Alafenamide)

Product Codes and Weight-based Dosing

Prior Authorization, Step Therapy, and Documentation

Background on Descovy and Clinical Rationale

Definitions and Product Details