Zepatier (elbasvir-grazoprevir)
Drugs for Infections : Drugs for Viral Infections
  • 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+