Prior Authorization Forms
Fuzeon (Enfuvirtide)
When completing Fuzeon access forms, please be sure to include all requested clinical information including CD4 lab measurements as well as two viral load measurements. IF your patient has never used Fuzeon, please submit TWO detectable viral load measurements within the last six-months in order to provide medical justification for starting Fuzeon. If your patient has received Fuzeon previously through another insurance payer (e.g. Medi-Cal, Medicare Part D, private insurance), you must provide TWO detectable viral load measurements within a six-month period prior to the date the patient started Fuzeon treatment.
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