Hepatitis Management

Hepatitis B Management Prior Authorization Request Form

Hepatitis C Management Prior Authorization Request Form

Covered Uses

• Pegylated interferon alfa-2a, lamivudine, adefovir, entecavir, and telbivudine
  • Chronic Hepatitis B
• Peginterferon alfa-2b
  • Hepatitis C
  • Retreatment of Chronic Hepatitis C
• Peginterferon alfa-2a
  • Hepatitis C
  • Hepatitis C with HIV coinfection in patients clinically stable

Exclusion Criteria

For Hepatitis B; - Transplanted patients

Required Medical Information

• For Hepatitis B (ICD-9: 070.22, 070.23, 070.32, 070.33)
  • Wild-type virus
    • HBs Ag positive for more than six months AND
    • Hbe Ag positive AND
    • HBV DNA by PCR more than 20,000 IU/mL AND
    • ALT less than or equal to 2 x ULN or ALT greater than 2 x ULN
  • Mutant virus
    • HBs Ag positive for more than six months AND
    • Hbe Ag negative AND
    • HBV DNA by PCR more than 20,000 IU/mL AND
    • ALT greater than 2 x ULN
  • Mutant virus
    • HBs Ag positive for more than six months AND
    • Hbe Ag negative AND
    • HBV DNA by PCR more than 2,000 IU/mL AND
    • ALT 1 to greater than 2 x ULN
  • Cirrhosis
    • HBs Ag positive for more than six months AND
    • Hbe Ag positive or negative AND
    • HBV DNA by PCR more than 2,000 IU/mL AND
    • Compensated cirrhosis or decompensated cirrhosis;
• For Hepatitis C (ICD-9 code 070.54, 070.51)
  • First prescription accompanied by results of the genotype test and viral load test

Age Restrictions

None

Prescriber Restrictions

• Gastroenterologist
• Infectologist

Coverage Duration

• HBV orals: up to six (6) months
• PEG-IFN: genotype 1 and 4 up to 48 weeks; genotype 2 and 3 up to 24 weeks.

Other Criteria

• For hepatitis C
  • Genotype 1 and Genotype 4:
    • Initial treatment will be authorized for 12 weeks
    • To continue treatment for 12 additional weeks must certify on the prescription that occurred less than 2 log decrease in viral load (week 12 of treatment) whose results show an early viral response and follow the prescription with the second viral load test.
      • NOTE: The second viral load test should be carried out at the end of the first 12 weeks of treatment.
    • To continue treatment for 24 additional weeks must send the results of the third test of viral load (week 24 of treatment) that evidences a negative viral load (HCV RNA negative).
      • NOTE: This second and third viral load testing should be conducted preferably in the clinical laboratory in which it conducted the initial viral load test. (HCV Negative).
  • Genotype 2 and Genotype 3:
    • Payment is authorized for treatment with these drugs only for 24 weeks. Only required proof of genotype and viral load at initiation of therapy.
• Retreatment for Hepatitis C
  • Retreatment with peginterferon plus ribavirin can be considered for non responders or relapsers who have previously been treated with non-pegylated interferon with or without ribavirin, or with peginterferon monotherapy, particularly if they have bridging fibrosis or cirrhosis
• See AASLD Practice Guidelines for Chronic Hepatitis B
• See AASLD Practice Guidelines: Diagnosis, Management, and Treatment of Hepatitis C
• See Management and Treatment of Hepatitis C Viral Infection: Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Office