Ribavirin
Defines medical necessity criteria for ribavirin (tablet and capsule) use in combination with specified direct-acting antiviral regimens for treatment of hepatitis C virus (HCV) infection across Commercial, HIM, and Medicaid lines of business, including age limits, dosing maxima, contraindications, and continuation criteria.
4Q 2024 annual review: removed references to brand Rebetol and Ribasphere Ribapak as ribavirin brands are no longer available; removed generic redirection criterion; removed requirement for 'chronic' in HCV diagnosis; removed specialist criterion and Appendix E; added disclaimer that medical management techniques beyond step therapy are not allowed.
4Q 2022 annual review: removed Copegus, Moderiba and Rebetol oral solution as no longer manufactured; added template generic redirection verbiage for generic ribavirin use; template changes applied to other sections.