Zepatier (elbasvir/grazoprevir) — Blue Cross Blue Shield of Alabama
hepatitis C genotype 1 or 4
Preferred products
- Epclusa (sofosbuvir/velpatasvir)
- Harvoni (ledipasvir/sofosbuvir)
- Ledipasvir/Sofosbuvir
- Sofosbuvir/Velpatasvir
- Mavyret (glecaprevir/pibrentasvir)
Initial criteria
- The patient has a diagnosis of hepatitis C genotype 1 or 4
- AND if genotype 1, the prescriber has provided the subtype
- AND if subtype 1a, the prescriber has tested the patient for NS5A polymorphisms
- AND ONE of the following: the patient is treatment naive OR was previously treated only with peg-interferon and ribavirin with or without an HCV protease inhibitor
- AND if the patient has an FDA labeled indication, then ONE of the following: the patient's age is within FDA labeling OR there is support for use for that age and indication
- AND the prescriber has screened the patient for current or prior hepatitis B viral infection
- AND if HBV screening was positive, the prescriber will monitor for HBV flare-up or reactivation during and after treatment
- AND if the client has preferred agent(s) for the patient’s specific factors, then ONE of the following: the patient has been treated with the requested non-preferred agent in the past 30 days OR has intolerance/hypersensitivity to ALL preferred agents OR has contraindication to ALL preferred agents OR there is support for use of the requested agent over preferred agent(s)
- AND ONE of the following: the prescriber is a specialist (gastroenterologist, hepatologist, or infectious disease) or has consulted one OR ALL of the following: patient is treatment naive AND patient does not have cirrhosis or has compensated cirrhosis AND requested agent supported in AASLD simplified treatment AND patient meets AASLD simplified treatment qualifications
- AND the patient does NOT have any FDA labeled contraindications to the requested agent
- AND the patient will use the requested agent in a regimen noted in Table 10
- AND the requested therapy duration does not exceed that in Table 10
Approval duration
up to duration of treatment per Table 10