Zepatier (grazoprevir/elbasvir) — Medica

Initial criteria

• Patient is ≥ 12 years of age OR patient weighs ≥ 30 kg
• Prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or a liver transplant physician
• Approve for 12 weeks if patient is treatment‑naïve OR previously treated with pegylated interferon + ribavirin only
• OR approve for 12 weeks if patient previously treated with pegylated interferon + ribavirin + HCV protease inhibitor AND medication prescribed in combination with ribavirin

Reauthorization criteria

• Patient is currently receiving Zepatier for an approved indication and approval period sufficient to complete total recommended course

Approval duration

12 weeks