I.  INDICATIONS

          The indications below including FDA-approved indications and compendial uses are
          considered a covered benefit provided that all the approval criteria are met and the
          member has no exclusions to the prescribed therapy.

          FDA-Approved Indication
          Fuzeon in combination with other antiretroviral agents is indicated for the treatment
          of human immunodeficiency virus (HIV)-1 infection in treatment-experienced patients
          with evidence of HIV-1 replication despite ongoing antiretroviral therapy.

          All other indications are considered experimental/investigational and not medically
          necessary.


    II.  CRITERIA FOR INITIAL APPROVAL

          Human immunodeficiency virus type 1 (HIV-1) infection
          Authorization of 12 months may be granted for treatment of HIV-1 infection when
          either of the following criteria is met:
          A.  The member has viremia despite 3 or more prior months of therapy with at least
               one appropriate regimen used to treat HIV.
          B.  The member has viremia and documented resistance or intolerance to at least
               one appropriate regimen used to treat HIV.


    III.  CONTINUATION OF THERAPY

          Authorization of 12 months may be granted for continued treatment in members
          requesting reauthorization for treatment of human immunodeficiency virus type 1
          (HIV-1) infection when the member has had a positive or stable virologic response to
          Fuzeon.