Viekira PAK (ombitasvir/paritaprevir/ritonavir + dasabuvir) — Blue Cross Blue Shield of Kansas

chronic hepatitis C virus (HCV) infection (genotypes 1–6)

Preferred products

Patient has an FDA labeled diagnosis for the requested agent
Requested agent is FDA labeled for the patient's genotype
If patient has FDA labeled indication, ONE of: (A) patient’s age is within FDA labeling OR (B) there is support for use in patient’s age for the indication
If FDA labeling requires hepatitis B screening, BOTH: (A) prescriber has screened for current/prior HBV infection AND (B) if positive, prescriber will monitor for HBV flare-up or reactivation during and after treatment
Patient does NOT have any FDA labeled contraindications to requested agent
ONE of: (A) prescriber is specialist (gastroenterologist, hepatologist, infectious disease) or has consulted one OR (B) ALL: patient is treatment naïve AND no cirrhosis or compensated cirrhosis AND requested agent is supported in AASLD simplified treatment AND patient meets qualifications for simplified treatment
If client has preferred agent(s) for patient’s factors (age, genotype, cirrhosis, treatment history), ONE of: (A) requested agent is preferred OR (B) patient recently treated with requested non-preferred OR (C) intolerance/hypersensitivity to ALL preferred OR (D) FDA labeled contraindication to ALL preferred OR (E) clinical information supports use of non-preferred over preferred agent
Patient meets all requirements and will use requested agent in a treatment regimen per Table 11 FDA labeling
Requested length of therapy does NOT exceed Table 11

up to duration of treatment per Table 11