Harvoni — Highmark
treatment experienced pediatric patients with chronic hepatitis C virus (HCV) infection
Preferred products
- Mavyret
- Epclusa AG
- Harvoni AG
Initial criteria
- age between 3 and 17 years
- diagnosis of chronic HCV (ICD-10: B18.2)
- prescriber documents any 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 misuse, abuse, and addiction risk
- 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 an offer of referral for substance abuse disorder treatment and care management was made
- if request is for a non-preferred product, member has a contraindication or is otherwise not a candidate for all preferred regimens
- if request is for Epclusa or Harvoni brand product, member has experienced therapeutic failure or intolerance to the authorized generic product