Epclusa AG — Highmark
treatment-experienced pediatric members with chronic HCV
Preferred products
- Epclusa
- Epclusa AG
- Harvoni
- Mavyret
Initial criteria
- age between 3 and 17 years
- diagnosis of chronic HCV (ICD-10: B18.2)
- prescriber documents previous therapies for chronic HCV with reason for discontinuation and/or failure
- prescriber provides cirrhosis status
- prescribed regimen is appropriate based on FDA-approved labeling and/or AASLD/IDSA guidelines
- prescriber attests that the 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 history of substance abuse within past 6 months, prescriber provides attestation that an offer of referral for substance abuse disorder treatment and care management was made
- if request is for a non-preferred product, member has contraindication or is otherwise not a candidate for all preferred regimens