Zepatier — Highmark
Hepatitis C virus (HCV) infection in treatment‑experienced kidney transplant patients
Preferred products
- Mavyret
- Zepatier
- Harvoni AG
- Epclusa AG
Initial criteria
- Member has diagnosis of hepatitis C virus (HCV) infection AND is a treatment‑experienced kidney transplant patient
- Member has HCV genotype, cirrhosis status, and prior treatment history consistent with regimens and durations listed in Table 6 (Treatment Experienced Kidney Transplant Patients)
- For genotype‑specific recommendations, member must use preferred product and duration matching Table 6 (e.g., Mavyret x 12 weeks, Harvoni AG x 12 weeks, Epclusa AG x 12 weeks, etc.)
- Requests for Viekira Pak will not be authorized
- Coverage is limited to FDA‑approved indications unless otherwise noted in approval criteria
- For Commercial closed‑formulary members, non‑formulary product requires meeting formulary exception criteria in addition to policy criteria
Reauthorization criteria
- If member is established on therapy, reauthorization allowed only for the remaining duration of course of therapy
Approval duration
up to 12 weeks (84 days); longer durations require additional plan authorization (PLA)