News
Guideline Update: Hepatitis C
Date: 04/30/19
Guideline Update: Hepatitis C
Thank you for your continued partnership with Ambetter from Coordinated Care. In order to better care for the health and wellbeing of our members we regularly review our clinical policy to ensure our members have the benefit of current industry standards.
GUIDELINE CHANGE: The clinical prior authorization guidelines for Hepatitis C treatment were updated July 2018. Coverage for direct acting combination antiretroviral medications has been expanded to allow for the treatment of all fibrosis score levels. Attached please find an initial approval checklist of the clinical policy requirements for treatment of Chronic Hepatitis C Infection.
PREFERRED PRODUCTS: Ambetter’s preferred combination antiretroviral is Mavyret. The formulary is reviewed monthly and agents are subject to change.
SPECIALTY PHARMACY: Acaria Health is our preferred specialty pharmacy for Ambetter members. Please call 1-800-511-5144 to speak with a representative about submitting a prescription for your qualifying patients.
Please take a few minutes to review your patients’ charts and the criteria on the next page to determine if they now meet the guidelines. To request a prior authorization review, please call 1-866-399-0928 or fax your request to 1-866-399-0929.
If you have any questions about this, please call us at 877.687.1197.
Initial Approval Checklist (Must Meet All) | |
| Diagnosis of chronic HCV infection as evidenced by detectable serum HCV RNA levels by quantitative assay in the last 6 months |
| Confirmed HCV genotype is one of the following (a, b, or c) a For treatment-naïve patients: genotypes 1, 2, 3, 4, 5, or 6 b For patients treatment-experienced with interferon (IFN)/pegylated-interferon (pegIFN), ribavirin (RBV), and/or sofosbuvir only: genotypes 1, 2, 3, 4, 5, or 6 c For patients treatment-experienced with either an NS5A inhibitor or an NS3/4A protease inhibitor: genotype 1
*Chart note documentation and copies of lab results are required* |
| Prescribed by or in consultation with a gastroenterologist, hepatologist, or infectious disease specialist |
| Patient age ≥ 18 years |
| Confirmation of Child-Pugh A status if cirrhosis is present |
| If contraindicated to Mavyret, member must use Epclusa® for applicable genotypes and treatment status, unless contraindicated or clinically significant adverse effects are experienced |
| Life expectancy ≥ 12 months with HCV treatment |
| Documented sobriety from alcohol and illicit IV drugs for ≥ 6 months prior to starting therapy, if applicable |
| Member is not treatment-experienced with both NS3/4A protease inhibitor AND NS5A inhibitors, such as combination therapies including Technivie™, Viekira™, and Zepatier® |
| Member agrees to participate in a medication adherence program |
| Prescribed regimen is consistent with an FDA or AASLD-IDSA recommended regimen |