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Epclusa — Highmark

pediatric patients with hepatitis C virus (HCV) infection

Preferred products

  • Mavyret
  • Harvoni AG
  • Epclusa AG

Initial criteria

  • age between 3 and 17 years
  • diagnosis of chronic HCV (ICD-10: B18.2) OR for Mavyret, diagnosis of acute (ICD-10: B17) or chronic HCV (ICD-10: B18.2)
  • no prior HCV treatment
  • prescriber provides cirrhosis status
  • regimen prescribed per FDA-approved labeling and/or AASLD/IDSA guidelines (see Table 3)
  • prescriber attests that member or guardian educated on potential adverse effects of alcohol or IV drug abuse
  • if member has alcohol use disorder, IV drug abuse, or history of substance abuse within past 6 months, prescriber attests that referral offer for substance abuse 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
  • if request is for brand Epclusa or Harvoni, member has experienced therapeutic failure or intolerance to the authorized generic product
  • if request is for Mavyret for 16 weeks, member has HCV genotype 3 AND is interferon-experienced