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DrugTrogarzo® (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.


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

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