Sovaldi — Highmark
Treatment‑experienced pediatric hepatitis C virus (HCV) infection
Preferred products
- Mavyret
- Epclusa
- Harvoni
Initial criteria
- age between 3 and 17 years
- diagnosis of chronic HCV (ICD‑10 B18.2)
- prescriber documents prior HCV therapies with reason for discontinuation and/or failure
- prescriber provides cirrhosis status
- prescribed regimen is appropriate per FDA labeling and/or AASLD/IDSA guidelines (table 4)
- prescriber attests that member or parent/guardian was educated on the potential adverse effects of alcohol or IV drug abuse
- 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‑use 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