Zepatier — Blue Cross Blue Shield of Montana

Initial criteria

• BOTH of the following:
• 1. The requested length of therapy does NOT exceed the length of therapy noted in Table 10 (FDA labeling) for the patient’s treatment regimen AND
• 2. The requested quantity (dose) does NOT exceed the program quantity limit

Approval duration

BCBSIL: 12 months; other plans: up to duration per Table 10