Trogarzo®

Drug - Trogarzo® (ibalizumab-uiyk) [Theratechnologies Inc.]

December 2018

Therapeutic area - Antiretroviral - HIV

Initial approval criteria

• Patient is at least 18 years old AND
• Patient has heavily treated multidrug resistant disease (including failure of at least one NRTI, NNRTI, and PI) AND
• Used in combination with antiretroviral therapy (ART) AND
• Patient is currently failing on their current antiretroviral regimen
• Initial approval is for 6 months

Renewal criteria

• Patient continues to meet initial criteria AND
• Disease response as indicated by a decrease in viral load AND
• Absence of unacceptable toxicity from the drug
• Renewal approval is for 6 months

Quantity limits

• Loading dose = 2000 mg (10 vials or 13.3mL)
• Maintenance dose = 800 mg (4 vials or 5.32 mL) every 2 weeks

Billing for Trogarzo

Trogarzo must be billed as a medical claim.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411