Epclusa — Blue Cross Blue Shield of Montana
Hepatitis C virus infection genotypes 1–6 in patients with or without cirrhosis, including decompensated cirrhosis and HCV/HIV-1 co-infection
Initial criteria
- The requested length of therapy does NOT exceed the length of therapy noted in Table 1 (FDA labeling) or Table 2 (AASLD/IDSA guidelines for decompensated cirrhosis) for the patient’s treatment regimen AND
- ONE of the following:
- A. The requested quantity (dose) does NOT exceed the program quantity limit OR
- B. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
- 1. The requested agent is Epclusa 200 mg/50 mg packets AND BOTH of the following:
- A. The requested quantity (dose) does NOT exceed 2 packets per day AND
- B. There is support for why the patient cannot take 1 tablet of the 400 mg/100 mg tablet OR
- 2. The requested agent is Epclusa 200 mg/50 mg tablet AND BOTH of the following:
- A. The requested quantity (dose) does NOT exceed 2 tablets per day AND
- B. There is support for why the patient cannot take 1 tablet of the 400 mg/100 mg tablet
Approval duration
12 months (BCBSIL) or up to duration of treatment per tables 1–2 (other plans)