Hepatitis C, Direct-Acting Antivirals

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
ELBASVIR/GRAZOPREVIR ZEPATIER TABLET Y PA Document  
LEDIPASVIR/SOFOSBUVIR HARVONI TABLET Y PA Document  
SOFOSBUVIR/VELPATASVIR EPCLUSA TABLET Y PA Document  
DACLATASVIR DIHYDROCHLORIDE DAKLINZA TABLET N PA Document  
OMBITA/PARITAP/RITON/DASABUVIR VIEKIRA XR TAB BP 24H N PA Document  
OMBITA/PARITAP/RITON/DASABUVIR VIEKIRA PAK TAB DS PK N PA Document Mar 26, 2015
OMBITASVIR/PARITAPREV/RITONAV TECHNIVIE TABLET N PA Document  
SIMEPREVIR SODIUM OLYSIO CAPSULE N PA Document Jan 30, 2014
SOFOSBUVIR SOVALDI TABLET N PA Document Jan 30, 2014