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

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Harvoni (ledipasvir/sofosbuvir)
• Sovaldi (sofosbuvir)
• Ledipasvir/Sofosbuvir
• Sofosbuvir/Velpatasvir
• Mavyret (glecaprevir/pibrentasvir)

Initial criteria

• ONE of the following: (A) Patient is treatment naive OR (B) Patient previously treated only with peginterferon and ribavirin with or without an HCV protease inhibitor
• If the patient has an FDA approved indication, ONE of the following: (A) Patient’s age is within FDA labeling for the requested indication OR (B) There is support for the use of the requested agent for the patient’s age for the requested indication
• Prescriber has screened for current or prior hepatitis B viral (HBV) infection
• If HBV screening positive, prescriber will monitor for HBV flare-up or reactivation during and after treatment
• If preferred agent(s) exist for the patient’s specific factors, ONE of the following: (1) Request is for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member OR (2) Patient treated with the requested non‑preferred agent in past 30 days OR (3) Patient currently stable on requested agent OR (4) Patient tried and had inadequate response to all preferred agents OR (5) Discontinued all preferred agents due to lack of efficacy/effectiveness/adverse event OR (6) Intolerance or hypersensitivity to all preferred agents OR (7) FDA labeled contraindication to all preferred agents OR (8) All preferred agents expected to be ineffective or cause barriers or harm OR (9) All preferred agents not in best interest based on medical necessity OR (10) Tried another drug in same class as all preferred agents with discontinuation due to lack of effect/adverse event OR (11) Support for use of requested non‑preferred agent over preferred
• ONE of the following: (A) Prescriber is a specialist in the patient’s diagnosis (gastroenterologist, hepatologist, or infectious disease) or has consulted with one OR (B) ALL of the following: (1) Treatment naive, (2) No cirrhosis or compensated cirrhosis, (3) Requested agent supported in AASLD guidelines for simplified treatment, (4) Patient meets all AASLD simplified treatment criteria
• Patient does not have any FDA labeled contraindications to requested agent
• Patient meets regimen and duration requirements in Table 10 (FDA labeling)

Approval duration

BCBSIL/BCBSMT: 6 months; others: per treatment duration (≥12 weeks BCBSNM); Ohio Fully Insured/HIM Shop: 12 months