Zepatier (elbasvir/grazoprevir) — Blue Cross Blue Shield of Kansas

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Harvoni (ledipasvir/sofosbuvir)
• Ledipasvir/Sofosbuvir
• Mavyret (glecaprevir/pibrentasvir)
• Vosevi (sofosbuvir/velpatasvir/voxilaprevir)

Initial criteria

• If genotype 1, prescriber must provide patient's subtype
• If subtype 1a, prescriber must test for NS5A polymorphisms
• ONE of the following: patient is treatment naïve OR previously treated with only peg-interferon and ribavirin with or without HCV protease inhibitor
• If the patient has an FDA labeled indication, ONE of the following: (A) patient's age is within FDA labeling OR (B) there is support for use in the patient's age
• Prescriber has screened patient for current or prior hepatitis B infection
• If HBV screening positive, prescriber will monitor for HBV flare-up or reactivation during and after treatment
• If client has preferred agent(s) for the patient’s factors (age, genotype, cirrhosis, treatment history), ONE of the following: (A) patient treated with requested non-preferred agent in past 30 days OR (B) intolerance or hypersensitivity to ALL preferred agents OR (C) FDA labeled contraindication to ALL preferred agents OR (D) support for use of requested non-preferred agent over preferred agents
• ONE of the following: (A) prescriber is a gastroenterologist, hepatologist, or infectious disease specialist or has consulted such specialist OR (B) ALL: patient is treatment naïve AND patient does NOT have cirrhosis or has compensated cirrhosis AND requested agent supported in AASLD guidelines for simplified treatment AND patient meets AASLD simplified treatment qualifications
• Patient does NOT have any FDA labeled contraindications to requested agent
• Patient meets all requirements and will use requested agent in regimen per Table 10 FDA labeling
• Requested length of therapy does NOT exceed duration noted in Table 10

Approval duration

up to duration of treatment per Table 10