Zepatier — Medical Mutual

Initial criteria

• Patient is age ≥ 12 years OR weighs ≥ 30 kg
• Medication is prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician
• Approve for 12 weeks if: (a) Patient is treatment-naïve OR previously treated with pegylated interferon + ribavirin only AND does NOT have a baseline NS5A polymorphism at amino acid positions 28, 30, 31, or 93; OR (b) Patient previously treated with pegylated interferon + ribavirin and an HCV protease inhibitor AND medication prescribed in combination with ribavirin
• Approve for 16 weeks if: Patient is treatment-naïve OR previously treated with pegylated interferon + ribavirin only AND has a baseline NS5A polymorphism at amino acid positions 28, 30, 31, or 93 AND medication is prescribed in combination with ribavirin

Reauthorization criteria

• Patient has been started on Zepatier and approval will continue to complete the recommended course duration

Approval duration

12 weeks OR 16 weeks as specified