ribavirin tablets (generic) — Cigna
Hepatitis C Virus (HCV)
Initial criteria
- Patient meets ONE of the following (i or ii):
- i. The medication is prescribed in combination with peginterferon alfa; OR
- ii. The medication is prescribed in combination with a direct-acting antiviral for HCV; AND
- The medication is prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician.
Approval duration
1 year