simeprevir (Olysio®)


Indications for Prior Authorization:

  • Treatment of chronic hepatitis C genotype 1a or 1b only

All of the following must be met as a condition for coverage:

  • Must not be used as monotherapy
  • Must be used with interferon alfa
  • Must screen for NS3 Q80K polymorphism at baseline
    • Treatment failure associated with HCV resistance to newly developed direct-acting antiviral agents is not an uncommon occurrence and poses a substantial problem to clinicians trying to re-treat patients who have failed available interferon-free treatments.
  • Must have compensated liver disease by ultrasound or biopsy stage F2, F3 or F4
  • Trial and failure of preferred agent(s) Epclusa, Harvoni, Vosevi

This Medication is Not Approvable for the following condition(s):

  • Hepatitis C with NS3 Q80k polymorphism
  • Any condition not listed above as an approved indication

Duration of Therapy:

Genotype 1

  • simeprevir + interferon alfa + ribavirin for 12 weeks
  • then continue interferon alfa + ribavirin for an additional 12 weeks

Genotype 1 prior partial or non-responders

  • simeprevir + interferon alfa + ribavirin for 12 weeks
  • then continue interferon alfa + ribavirin for an additional 36 weeks


  • 150 mg po daily with food

Discontinuation Schedule:

  • HCV/RNA > 25 IU/ml       at week 4                           discontinue all medications
  • HCV/RNA > 25 IU/ml       at week 12 or 24               discontinue interferon alfa + ribavirin


Last review date: September 12, 2018

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.

Press Esc to cancel

El sitio Web al que está siendo transferido no es provisto por WHA. Las Condiciones de Uso y las Prácticas de Privacidad en Internet de WHA no se aplican a este sitio Web asociado que usted está usando. Revise las políticas sobre la privacidad y condiciones de uso de este sitio Web asociado. WHA no tiene control sobre la exactitud, la totalidad o la actualidad del contenido del sitio Web asociado. WHA no puede garantizar que los servicios de traducción de idiomas estarán disponibles en el sitio vinculado.

Presione «Esc» para cancelar