Mavyret — Blue Cross Blue Shield of Montana

Initial criteria

• BOTH of the following:
• 1. The requested length of therapy does NOT exceed the length of therapy noted in Table 5 (FDA labeling) for the patient’s treatment regimen AND
• 2. ONE of the following:
• A. The requested quantity (dose) does NOT exceed the program quantity limit OR
• B. The requested quantity (dose) exceeds the program quantity limit AND ALL of the following:
• 1. The requested agent is Mavyret 50 mg/20 mg packets AND
• 2. The requested quantity (dose) does NOT exceed 6 packets per day AND
• 3. There is support for why the patient cannot take 3 tablets of the 100 mg/40 mg tablet

Approval duration

BCBSIL: 12 months; other plans: up to duration per Table 5