Hepatitis C direct-acting antivirals (off-label indications) — Blue Cross Blue Shield of Illinois

Initial criteria

• Patient does NOT have any FDA labeled contraindications to the requested agent AND ONE of the following: patient has another FDA labeled indication for the requested agent and route of administration OR patient has another indication supported in compendia (DrugDex level 1/2A/2B, AHFS-DI supportive text, NCCN 1 or 2A, Clinical Pharmacology supportive narrative, Lexi-Drugs evidence level A, or peer-reviewed medical literature) OR prescriber submitted two peer-reviewed journal articles supporting the proposed use as generally safe and effective (randomized, double-blind, placebo-controlled studies acceptable; case studies not acceptable)

Approval duration

12 months