Primary navigation

    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

    back to top