- Quantity Limit: 84 tablets per 720 days (12 weeks)
- Prior Authorization: Antiviral: Hepatitis C (HCV):
Documented Diagnosis: Yes
Duration: 16 week(s)
- Antiviral: Hepatitis C (HCV):
Duration: 16 week(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented Genotype(s): 1 of Genotype 1;Genotype 4
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: Yes
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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