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Florida Medicaid HCV Criteria for Olysio (simeprevir)
  Olysio criteria pdf:
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Original Development Date:
Original Effective Date:
Revision Date:
February 13, 2014;
April 25, 2014; May 12, 2014; June 30, 2014
Prior Authorization Criteria

1 - Must be prescribed by a related specialist.
2 - Requests for Olysio in combination with peginterferon alfa and ribavirin as triple-therapy will be referred to alternative preferred HCV protease inhibitors (Incivek or Victrelis).
3 - Olysio in combination with Sovaldi:
HCV & HCV/HIV-1 Co-Infection - Genotype 1 (Interferon Ineligible)
Length of Authorization: Up to 12 weeks
For re-authorization for continuation of treatment with sofosbuvir, the member must
have an HCV RNA viral load performed at or approaching 4 weeks after initiation of
treatment to determine response to therapy. Requests for renewal will NOT be authorized
in members who have not achieved a ≥ 2 log reduction in HCV RNA or HCV RNA < 25 IU/ml around 4 weeks.
Evidence of Stage 3 or Stage 4 hepatic fibrosis including one of the following
Prior to initiating therapy, patients should be screened for NS3 Q80K polymorphism; alternative therapy should be considered in patients with this polymorphism

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