Health Net
Viekira XR (ombita-paritap-riton-dasabuvir)
Drugs for Infections : Drugs for Viral Infections
  • Prior Authorization: Antiviral: Hepatitis C (HCV):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 12 week(s)
    Reauthorization Required: Yes

  • Antiviral: Hepatitis C (HCV):
    Age Requirement: >= 18
    Duration: 12 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: <= 12 week(s)
    Documented Genotype(s): Genotype 1
    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: No

  • Step Therapy: Antiviral: Hepatitis C (HCV):
    ST Single Brand