Zepatier (grazoprevir/elbasvir tablets – Merck) — Cigna

Initial criteria

• Patient is age ≥ 12 years OR patient weighs ≥ 30 kg; AND
• If approving for 12 weeks: Patient is treatment-naïve OR previously treated with pegylated interferon + ribavirin only AND patient does NOT have a baseline NS5A polymorphism at amino acid positions 28, 30, 31, or 93; OR
• If approving for 12 weeks: Patient has previously been treated with pegylated interferon + ribavirin + an HCV protease inhibitor AND the medication will be prescribed in combination with ribavirin; OR
• If approving for 16 weeks: Patient is treatment-naïve OR previously treated with pegylated interferon + ribavirin only AND patient has a baseline NS5A polymorphism at amino acid positions 28, 30, 31, or 93 AND the medication will be prescribed in combination with ribavirin; AND
• The medication is prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician.

Reauthorization criteria

• Patient is currently receiving Zepatier for an approved indication and requires additional time to complete a course of therapy (approve the remaining duration to complete total recommended treatment length).

Approval duration

12 or 16 weeks