Harvoni — Blue Cross Blue Shield of Montana

Initial criteria

• The requested length of therapy does NOT exceed the length of therapy noted in Table 3 (FDA labeling) or Table 4 (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 Harvoni 45 mg/200 mg oral pellets AND BOTH of the following:
• A. The requested quantity (dose) does NOT exceed 2 packets daily AND
• B. There is support for why the patient cannot take 1 tablet of Harvoni 90 mg/400 mg strength OR
• 2. The requested agent is Harvoni 45 mg/200 mg tablet AND BOTH of the following:
• A. The requested quantity (dose) does NOT exceed 2 tablets daily AND
• B. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit

Approval duration

12 months (BCBSIL) or up to duration of treatment per tables 3–4 (other plans)