Hepatitis C
Preferred Drug - Mavyret pellet pack, Mavyret tablet
Nonpreferred Drug - Epclusa pellet pack, Epclusa tablet, Harvoni pellet pack, Harvoni tablet, Ledipasvir/Sofosbuvir, Sofosbuvir/Velpatasvir, Sovaldi pellet pack, Sovaldi tablet, Vosevi, Zepatier
January 2025
Therapeutic area - Hepatitis C Agents
- Preferred drugs will not require prior authorization.
- Nonpreferred drugs must meet prior authorization criteria before payment.
- Prior authorization requests for patients with mixed genotypes will be evaluated on a case-by-case basis.
Prior authorization criteria for nonpreferred drugs:
- Patient meets the age limit and has the diagnosis described in the FDA-approved label of the requested drug; AND
- Patient is NOT a candidate for the preferred drugs; AND
- Patient’s chart notes indicate that a comprehensive review of all existing medications has been conducted; and clinically significant drug interactions with the preferred drug cannot be mitigated; AND
- Clinical documentation of patient’s liver cirrhosis status (e.g. no cirrhosis, compensated cirrhosis, etc.) that corresponds to the requested therapy duration; AND
- Patient’s prescribed regimen must align with the dosage recommendation described in the FDA-approved label or in AASLD/IDSA HCV guidelines; AND
- Patient must NOT have any one of the following:
- Pregnancy; OR
- Severe end organ disease and not eligible for transplant (e.g. liver, heart, lung, kidney); OR
- Clinically-significant illness or any other major medical disorder that may interfere with patients’ abilities to complete a course of treatment; OR
- Patients who, in the professional judgment of the primary treating clinician, would not achieve a long-term clinical benefit from HCV treatment (e.g. patients with multisystem organ failure; receiving palliative care or in hospice; significant pulmonary or cardiac disease; and malignancy outside of the liver not meeting oncologic criteria for cure); OR
- Decompensated liver disease with CPT > 12 or MELD > 20: OR
- MELD ≤ 20 and one of the following:
- Cardiopulmonary disease that cannot be corrected and is a prohibitive risk for surgery
- Malignancy outside the liver not meeting oncologic criteria for cure
- Hepatocellular carcinoma
- Intrahepatic cholangiocarcinoma
- Hemangiosarcoma; OR
- Contraindication to requested drug or drug combination; OR
- Requested duration of therapy is longer or shorter than therapy duration listed in FDA-approved label of requested drug; OR
- Indeterminate HCV genotype
Quantity limits:
- Requested regimens must meet treatment dosage and duration described in the FDA-approved label or in AASLD/IDSA HCV guidelines
Questions?
Provider Call Center 844-575-7887