non-preferred hepatitis C direct-acting antivirals — Blue Cross Blue Shield of Texas

Initial criteria

• The request is for a BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR the requested agent is a preferred agent for the patient’s specific factors OR the patient has been treated with the requested non-preferred agent in the past 30 days OR the patient is currently being treated with the requested non-preferred agent and is stable on it (chart notes required) OR the patient has tried and had an inadequate response to ALL preferred agents for the patient’s specific factors (chart notes required) OR ALL preferred agents were discontinued due to lack of efficacy/effectiveness or adverse event (chart notes required) OR the patient has intolerance or hypersensitivity to ALL preferred agents (chart notes required) OR the patient has an FDA labeled contraindication to ALL preferred agents (chart notes required) OR ALL preferred agents are expected to be ineffective or cause clinically significant issues in adherence, comorbid conditions, daily function, or harm (chart notes required) OR ALL preferred agents are not in the best medical interest of the patient (chart notes required) OR the patient has tried another drug in the same pharmacologic class as ALL preferred agents and discontinued due to lack of efficacy/effectiveness or adverse event (chart notes required) OR there is support for the use of the requested non-preferred agent over preferred agents
• The patient meets all requirements and will use the requested agent in a treatment regimen noted in Table 11 (FDA labeling)
• The requested length of therapy does not exceed the length of therapy in Table 11 (FDA labeling)

Approval duration

6 months (BCBSIL, BCBSMT) or up to duration of treatment per FDA Table 11 (≥12 weeks BCBSNM)