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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

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