Viekira Pak (ombitasvir-paritaprevir-ritonavir-dasabuvir) — CareFirst (Caremark)
Chronic hepatitis C virus (HCV) genotype 1a infection without cirrhosis or with compensated cirrhosis (in combination with ribavirin)
Initial criteria
- Member age ≥ 18 years
- Diagnosis of chronic HCV infection with genotype 1a or 1b confirmed
- Prescribed by or in consultation with a provider experienced in managing HCV infection
- Member does not have decompensated cirrhosis or moderate/severe hepatic impairment (Child-Turcotte-Pugh class B or C)
- For genotype 1b infection: member without cirrhosis or with compensated cirrhosis AND treatment-naïve or failed prior treatment with peginterferon alfa and ribavirin
- For genotype 1a or mixed/unknown genotype 1 infection: Viekira Pak must be used in combination with ribavirin; member without cirrhosis who is treatment-naïve or failed prior treatment with peginterferon alfa and ribavirin OR member with compensated cirrhosis who is treatment-naïve or failed prior treatment with peginterferon alfa and ribavirin
- For recurrent HCV post liver transplantation: recurrent HCV genotype 1 infection (any subtype) AND Metavir fibrosis score ≤ 2
- For HCV and HIV coinfection: member meets criteria for approval of the requested regimen above
Reauthorization criteria
- Continuation requests must meet all initial coverage criteria
Approval duration
up to 12 weeks or up to 24 weeks depending on genotype, cirrhosis status, and clinical scenario