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Pegasys — Blue Cross Blue Shield of New Mexico

chronic hepatitis C genotype 1, 2, 3, or 4

Initial criteria

  • ONE of the following:
  • A. The patient has a diagnosis of chronic hepatitis B AND BOTH of the following: 1. The infection has been confirmed by serological markers AND 2. The patient has not been administered peg-interferon for 48 weeks or longer for treatment of chronic hepatitis B OR
  • B. The patient has a diagnosis of chronic hepatitis C genotype 1, 2, 3, or 4 AND the requested agent will be used in a treatment regimen AND length of therapy recommended for the patient’s genotype as noted in Table 1 or 2 (FDA labeling) OR
  • C. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • D. The patient has another non-oncology indication that is supported in compendia for the requested agent and route of administration OR
  • E. The patient has an oncology indication that is supported in compendia (meeting all compendia-listed requirements).
  • AND if the patient has an FDA labeled indication, ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication OR
  • B. There is support for using the requested agent for the patient’s age for that indication.
  • AND the requested quantity (dose) is within FDA labeled dosing or supported in compendia.
  • AND the patient does NOT have any FDA labeled contraindications.
  • Special rules for NM Fully Insured or NM HIM members: 1. No labeled contraindications AND 2. Indication is a rare disease AND 3. has another FDA labeled or compendia-supported indication.
  • Special rules for OH Fully Insured or HIM Shop members: 1. Resides in Ohio AND 2. No labeled contraindications AND 3. another FDA labeled or compendia-supported indication OR prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective.

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process.
  • AND ONE of the following:
  • A. The patient has chronic hepatitis B AND has NOT been administered peg-interferon for 48 weeks or longer for treatment of chronic hepatitis B OR
  • B. The patient has chronic hepatitis C genotype 1, 2, 3, or 4 AND did not complete the duration of therapy for their genotype per Table 1 or 2 OR
  • C. The patient has a diagnosis other than chronic hepatitis B or C AND has had clinical benefit with the requested agent.
  • AND the requested quantity (dose) is within FDA labeled dosing or supported in compendia, AND there are no labeled contraindications.

Approval duration

varies (Hepatitis B up to 48 weeks; Hepatitis C per regimen table; all other indications 12 months)