Pharmacy Prior Authorization Criteria

Selzentry (maraviroc)

For diagnosis of CCR5-tropic HIV-1
Indicated in combination with other antiretroviral agents for the treatment of only CCR5‑tropic human immunodeficiency virus type 1 (HIV‑1) infection in adult and pediatric patients weighing at least 2 kg.
Limitations of Use: SELZENTRY is not recommended in patients with dual/mixed- or CXCR4-tropic HIV-1

Prior Authorization

Length of Approval: 12 Month(s)

Diagnosis of CCR5-tropic HIV-1 infection as confirmed by a highly sensitive tropism assay

AND

Patient is currently taking or will be prescribed an optimized background antiretroviral therapy regimen

AND

2024-10-11, 2023-11-20, 2022-11-18, 2022-04-05, 2021-11-19, 2021-05-26, 2021-05-25, 2020-11-17, 2019-11-01

Selzentry Prescribing Information. ViiV Healthcare. Durham, NC. September 2022.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. 2023. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv. Accessed September 14, 2023.

2024-10-11: 2024 annual review. No changes.
2023-11-20: Annual review: no changes to criteria. background updates.
2022-11-18: Annual review - updated references.
2022-04-05: Added new generic maraviroc 150mg and 300mg tablets to guideline. Updated background and references.
2021-11-19: Annual review: no criteria changes
2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
2020-11-17: Background Updated
2019-11-01: Annual Review: Allow continuation of prior therapy, updated background, changed to non-specialty formulary.