Peginterferon — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient does NOT have any FDA labeled contraindications to the requested agent
• If the indication is supported, compendia-level evidence must be NCCN 1 or 2a, AHFS, or DrugDex 1 or 2a

Reauthorization criteria

• Patient was previously approved through the plan’s prior authorization process AND
• One of the following:
• A. Patient has chronic hepatitis B AND has NOT been administered peginterferon for 48 weeks or longer OR
• B. Patient has chronic hepatitis C genotype 1, 2, 3, or 4 AND did not complete the duration of therapy appropriate to the patient’s genotype as noted in Table 1 or 2 OR
• C. Patient has an indication other than chronic hepatitis B or C AND has had clinical benefit with the requested agent AND
• Requested dose is within FDA labeled dosing or supported in compendia AND
• Patient does NOT have any FDA labeled contraindications

Approval duration

Hepatitis B: up to 48 weeks; Hepatitis C: per Table 1 or 2 (12–48 weeks); other indications: 12 months or less per label/compendia