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; OR (b) Patient previously treated with pegylated interferon + ribavirin + an HCV protease inhibitor AND Zepatier 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