Harvoni AG — Highmark
treatment-naïve kidney transplant patients with HCV
Preferred products
- Zepatier
- Harvoni
- Epclusa
Initial criteria
- age ≥ 18 years
- diagnosis of chronic HCV (ICD-10: B18.2) OR, if the 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 cirrhosis status
- prescribed regimen is appropriate based on patient characteristics per 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
- appropriate resistance-associated substitutions (RASs) testing has been performed based on agent and genotype
- if request is for a non-preferred product, member has contraindication or is otherwise not a candidate for all preferred regimens