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 patient is treatment-naïve
• Approve for 16 weeks if patient previously treated with pegylated interferon + ribavirin and Zepatier will be 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