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Sovaldi — Highmark

Treatment‑naïve 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) OR, if request is for Mavyret, diagnosis of acute (ICD‑10 B17) or chronic HCV (ICD‑10 B18.2)
  • no prior HCV treatment
  • prescriber provides cirrhosis status
  • prescribed regimen is appropriate per FDA labeling and/or AASLD/IDSA guidelines (table 3)
  • 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
  • if request is for Mavyret for 16 weeks, all of: HCV genotype 3 AND interferon‑experienced