- Step Therapy Applies
- Prior Authorization: Antiviral: Hepatitis C (HCV):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 3
Duration: 24 week(s)
Reauthorization Required: Yes
- Antiviral: Hepatitis C (HCV):
Age Requirement: >= 3
Duration: 24 week(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Gastroenterologist;Hepatologist;Infectious Disease Specialist
Reauthorization Required: Yes
Duration of Reauthorization: <= 24 week(s)
Documented Genotype(s): 1 of Genotype 1;Genotype 2;Genotype 3;Genotype 4;Genotype 5;Genotype 6
History of Substance Abuse: No
If History of Substance Abuse, Drug Abstinence Duration: N/A
If History of Substance Abuse, Appropriate Clean Drug Screen: No
Policy Contains a Once in a Lifetime Restriction: No
Co-Infection with Hepatitis B Prohibited in the Policy: No
Extra-hepatic Disease Prohibited in Policy: No
Treatment Duration Extended for Hepatocellular Carcinoma: No
Concomitant Therapy with RBV: No
Concomitant Therapy with RBV + IFN: No
Concomitant Therapy with Daklinza: No
Concomitant Therapy with Sovaldi: No
Patient Must Not Have Been Previously Treated With a NS3-4A: No
Patient Must Not Have Been Previously Treated With a NS-5A: No
Fibrosis Score Required for Authorization: Yes
Hepatic Fibrosis Score Required in Policy: FV0+
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