Pharmacy Prior Authorization Criteria

Idvynso (doravirine and islatravir) - PA, NF

Indications for Prior Authorization

Idvynso (doravirine and islatravir)

• For diagnosis of Treatment of HIV-1 Infection
  Indicated as a complete regimen for the treatment of HIV-1 infection in adults to replace the current antiretroviral regimen in those who are virologically-suppressed (HIV-1 RNA less than 50 copies per mL) on a stable antiretroviral regimen with no history of virologic treatment failure and no known substitutions associated with resistance to doravirine.

Criteria

Idvynso

Prior Authorization

Length of Approval: 12 Month(s)
For diagnosis of Treatment of HIV-1 Infection

• All of the following:
• Diagnosis of HIV-1 infection
AND
• Patient is currently virologically suppressed (i.e., HIV-1 RNA less than 50 copies/mL) on a stable, uninterrupted oral antiretroviral regimen for at least 3 months [A]
AND
• Requested medication will not be used in combination with another drug therapy (e.g., Biktarvy, Dovato) for the treatment of HIV infection
AND
• Patient has no history of treatment failure or known/suspected resistance to doravirine
AND
• Prescribed by or in consultation with a clinician with HIV expertise
OR
• For continuation of prior therapy

Idvynso

Non Formulary

Length of Approval: 12 Month(s)
For diagnosis of Treatment of HIV-1 Infection

• Submission of medical records (e.g., chart notes) or paid claims confirming continuation of prior therapy, defined as no more than a 45 days gap in therapy
OR
• All of the following:
• Submission of medical records (e.g., chart notes) confirming diagnosis of HIV-1 infection
AND
• Submission of medical records (e.g., chart notes) confirming patient is currently virologically suppressed (i.e., HIV-1 RNA less than 50 copies/mL) on a stable, uninterrupted oral antiretroviral regimen for at least 3 months [A]
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming requested medication will not be used in combination with another drug therapy (e.g., Biktarvy, Dovato) for the treatment of HIV infection
AND
• Submission of medical records (e.g., chart notes) confirming patient has no history of treatment failure or known/suspected resistance to doravirine
AND
• Prescribed by or in consultation with a clinician with HIV expertise

P & T Revisions

2026-07-21, 2026-07-07

References

1. Idvynso Prescribing Information. Merck Sharp & Dohme LLC. Rahway, NJ. April 2026.

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End Notes

1. In clinical studies, participants must have been stably suppressed on their baseline regimen for at least 3 months prior to trial entry. [1]

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Revision History

• 2026-07-21: update guideline
• 2026-07-07: New UM PA Criteria

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