Zepatier — Blue Cross Blue Shield of New Mexico
Hepatitis C virus infection (genotypes 1 and 4 per FDA labeling)
Initial criteria
- Requested length of therapy does NOT exceed the length of therapy noted in Table 10 (FDA labeling) for the patient’s treatment regimen
- Requested quantity (dose) does NOT exceed the program quantity limit
Approval duration
BCBSIL: 12 months; Others: up to duration per Table 10 (12–16 weeks per FDA labeling)