Epclusa — Highmark

Preferred products

• Mavyret
• Epclusa
• Harvoni

Initial criteria

• age ≥ 18 years
• 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)
• history of kidney transplant
• no prior HCV treatment
• prescriber provides member’s cirrhosis status
• prescribed regimen is appropriate per FDA labeling and/or AASLD/IDSA guidelines (see table 5)
• prescriber attests member (or guardian) educated on potential adverse effects of alcohol or IV drug abuse including risks of misuse, abuse, and addiction
• if member has alcohol use disorder, IV drug abuse, or substance abuse within past 6 months, prescriber attests an offer of referral for substance abuse treatment and care management was made
• appropriate resistance-associated substitutions (RASs) testing performed based on agent and genotype
• if request is for a non-preferred product, member has contraindication or is not a candidate for all preferred regimens

Approval duration

per recommended treatment duration; up to 12 weeks (84 days) unless regimen requires longer per Table 5