Epclusa AG — Highmark
chronic hepatitis C virus (HCV) in treatment-experienced adults
Preferred products
- Vosevi
- Harvoni
- Epclusa
Initial criteria
- age ≥ 18 years
- member has a diagnosis of chronic HCV (ICD-10: B18.2)
- prescriber documents all previous HCV therapies used and reason for discontinuation and/or failure
- 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 IV drug abuser OR has 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 non-preferred product, member has contraindication or is otherwise not a candidate for all preferred regimens