Epclusa AG — Highmark

chronic hepatitis C virus (HCV)

Preferred products

age ≥ 18 years
member has a diagnosis of chronic HCV (ICD-10: B18.2) OR if request is for Mavyret, diagnosis of acute (ICD-10: B17) or chronic HCV (ICD-10: B18.2)
member has not received prior HCV treatment
prescriber provides cirrhosis status AND liver transplant history
member is prescribed an appropriate regimen based on patient characteristics per FDA-approved labeling and/or AASLD/IDSA guidelines
prescriber attests member or parent/guardian has been educated on potential adverse effects of alcohol or IV drug abuse, including risk of misuse, abuse, and addiction
if member has alcohol use disorder OR is an IV drug abuser OR has a history of substance abuse within past 6 months, prescriber attests that an offer of referral for substance abuse disorder treatment and care management was made
member has appropriate RASs testing performed based on agent and genotype if applicable
if request is for Harvoni and member is genotype 1a or 1b, treatment duration requirements met per criteria for 8-week or 12-week therapy
if request is for Mavyret for 12 weeks, member is HIV/HCV co-infected OR had a prior liver transplant
if request is for a non-preferred product, member has contraindication or is otherwise not a candidate for all preferred regimens