Pegasys (peginterferon alfa-2a) — CareFirst (Caremark)

Adult T-cell leukemia/lymphoma

Initial criteria

For chronic hepatitis C virus (HCV) infection: Refer to the SGM of requested regimen for the specific criteria for approval and approval durations.
For chronic hepatitis B virus (HBV) infection (including hepatitis D virus [HDV] coinfection): Member has chronic HBV infection, including HDV coinfection; authorization may be granted for treatment.
For chronic hepatitis E virus (HEV) infection in liver transplant recipients: Member is a liver transplant recipient AND has had an inadequate response, intolerance, or contraindication to ribavirin.
For myeloproliferative neoplasms (essential thrombocythemia, polycythemia vera, symptomatic lower-risk myelofibrosis): Authorization may be granted for treatment.
For systemic mastocytosis: Authorization may be granted for treatment.
For adult T-cell leukemia/lymphoma: Authorization may be granted for treatment.
For mycosis fungoides/Sezary syndrome: Authorization may be granted for treatment.
For primary cutaneous CD30+ T-cell lymphoproliferative disorders: Authorization may be granted for treatment.
For hairy cell leukemia: Authorization may be granted for treatment.
For Erdheim-Chester disease: Authorization may be granted for treatment.
For chronic myeloid leukemia in pregnancy: Authorization may be granted for treatment.

For chronic HCV infection, chronic HBV infection (including HDV coinfection), or chronic HEV infection in liver transplant recipients: All requirements in the coverage criteria must continue to be met.
For myeloproliferative neoplasms: Authorization may be granted if the member is experiencing benefit from therapy as evidenced by improvement in symptoms and/or disease markers (e.g., morphological response, reduction or stabilization in spleen size, improvement of thrombocytosis/leukocytosis).
For systemic mastocytosis: Authorization may be granted if the member is experiencing benefit from therapy as evidenced by improvement in symptoms and/or disease markers (e.g., reduction in serum and urine metabolites of mast cell activation, improvement in cutaneous lesions, skeletal disease, bone marrow mast cell burden).
For all other indications: Authorization may be granted if the member shows no evidence of unacceptable toxicity or disease progression while on the current regimen.

Up to 48 weeks for HBV (including HDV); 12 months for all other specified indications