Victrelis - Hep C - Protease Inhibitors
| Covered Uses: | All FDA approved indications not otherwise excluded from Part D. |
|---|---|
| Exclusion Criteria: | Coverage is not provided for genotypes other than type 1. Previous failure to Incivek or Victrelis. |
| Required Medical Information: | Chronic Hep C, in patients with genotype 1 who have a quantifiable viral load. Must be used in combination with a pegylated interferon and ribavirin. |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 11 months |
| Other Criteria: |
Last Modified on 12/20/2012