Sovaldi — CareFirst (Caremark)
Chronic hepatitis C virus infection genotype 1, 2, 3, or 4 without cirrhosis or with compensated cirrhosis as part of a combination antiviral regimen
Initial criteria
- Prescribed by or in consultation with a provider experienced in management of hepatitis C virus infection
- For genotype 1 or 4 infection in adults: treatment-naïve when used in combination with peginterferon alfa and ribavirin; authorization up to 12 weeks
- For genotype 1 infection in adults with documented interferon ineligibility: combination with ribavirin; authorization up to 24 weeks; interferon ineligibility defined by one or more of the following — intolerance to IFN, autoimmune disorder, hypersensitivity to PEG-IFN, major uncontrolled depressive illness, baseline neutrophil count < 1,500 cells/mcL, platelet count < 90,000 cells/mcL, hemoglobin < 10 g/dL, or history of pre-existing cardiac disease
- For genotype 2 infection (age ≥ 3 years): treatment-naïve or failed prior PEG-IFN ± ribavirin therapy; combined with ribavirin; authorization up to 12 weeks
- For genotype 3 infection (age ≥ 3 years): treatment-naïve or failed prior PEG-IFN ± ribavirin therapy; combined with ribavirin; authorization up to 24 weeks
- For hepatocellular carcinoma awaiting liver transplantation with genotype 1–4: authorization up to 48 weeks or until transplantation, whichever occurs first
- For HCV infection in combination with Mavyret (with ribavirin): age ≥ 3 years; must meet approval criteria for components; authorization up to 24 weeks
- For HCV/HIV coinfection: meets same regimen approval criteria as above
Reauthorization criteria
- For continuation of therapy, member must continue to meet all initial coverage criteria