Epclusa — Highmark
treatment experienced kidney transplant patients with chronic hepatitis C virus (HCV) infection
Preferred products
- Mavyret
Initial criteria
- age ≥ 18 years
- diagnosis of chronic HCV (ICD-10: B18.2)
- history of kidney transplant
- prescriber documents previous therapies used for chronic HCV with reason for discontinuation and/or failure
- prescriber provides member’s cirrhosis status
- member is prescribed an appropriate regimen based on patient characteristics per FDA-approved labeling and/or AASLD/IDSA guidelines
- prescriber attests the member or parent/guardian has been educated on 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 attests that a referral offer for substance abuse disorder treatment and care management was made
- member has had appropriate resistance-associated substitutions (RASs) testing based upon agent and genotype
- 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 product, member has experienced therapeutic failure or intolerance to the authorized generic product