Zepatier Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Zepatier will be approved when ALL of the following are met:

1. The patient has a diagnosis of hepatitis C confirmed by serological markers
   AND

2. The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection and if positive, will monitor the patient for HBV flare-up or reactivation during and after treatment with the requested medication
   AND

3. The requested medication will be used in a treatment regimen and length of therapy that is supported in FDA approved labeling or AASLD/IDSA guidelines for the patient’s diagnosis and genotype
   AND

4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, hepatologist or infectious disease) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
   AND

5. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND

6. The requested dose is within FDA labeled dosing or supported in AASLD/IDSA guideline dosing for the requested indication
   AND

7. If genotype 1, the patient’s subtype has been identified and provided
   AND

8. If genotype 1a, the prescriber has tested the patient for the presence of virus with NS5A resistance-associated polymorphisms
   AND

9. ONE of the following:

   1. There is evidence of a claim that the patient has been treated with the requested medication within the past 90 days
      OR
   2. The prescriber states the patient has been treated with the requested medication within the past 90 days
      OR
   3. The patient has an FDA labeled contraindication or hypersensitivity to the preferred medication (Mavyret) for supported genotypes
      OR
   4. The prescriber has provided information based on FDA approved labeling or AASLD/IDSA guidelines supporting the use of the non-preferred medication for the patient’s diagnosis and genotype over the preferred medication (Mavyret) for supported genotypes

Length of Approval: 8-16 weeks based on FDA approved labeling or supported in AASLD/IDSA guidelines: https://www.hcvguidelines.org/