Mavyret — Blue Cross Blue Shield of New Mexico
Hepatitis C virus infection (various genotypes per FDA labeling)
Initial criteria
- Requested length of therapy does NOT exceed the length of therapy noted in Table 5 (FDA labeling) for the patient's treatment regimen
- 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; Others: up to duration per Table 5 (8–16 weeks per FDA labeling)