non-preferred Hepatitis C direct-acting antivirals — Blue Cross Blue Shield of Illinois

Initial criteria

• Request is for a BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR the requested agent is a preferred agent for the patient's specific factors OR the patient has been treated with or is currently stable on the requested non-preferred agent OR the patient has tried and had inadequate response to ALL of the preferred agents OR the preferred agents were discontinued due to lack of efficacy/effectiveness/adverse event OR the patient has intolerance, hypersensitivity, or FDA labeled contraindication to ALL preferred agents OR ALL preferred agents are expected to be ineffective, unsafe, or clinically inappropriate based on patient-specific characteristics OR ALL preferred agents are not in the patient's best interest based on medical necessity OR the patient tried another drug in the same pharmacologic class/mechanism of action as the preferred agents which was discontinued due to lack of efficacy/effectiveness/adverse event OR there is support for the use of the requested non-preferred agent over preferred agents [chart notes required]
• Patient meets all requirements and will use the requested agent in a treatment regimen noted in Table 11 (FDA labeling)
• Requested length of therapy does NOT exceed the length of therapy noted in Table 11 (FDA labeling) for the patient’s treatment regimen

Approval duration

6 months (BCBSIL/BCBSMT); for other plans up to duration per Table 11 (at least 12 weeks for BCBSNM)