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Mavyret (glecaprevir/pibrentasvir) — Blue Cross Blue Shield of Texas

Hepatitis C virus (HCV) genotype 1, 4, 5, or 6 infection

Preferred products

  • Harvoni (ledipasvir/sofosbuvir)
  • Ledipasvir/Sofosbuvir

Initial criteria

  • The patient has a diagnosis of hepatitis C genotype 1, 4, 5, or 6 AND
  • The prescriber has provided the patient’s baseline HCV RNA level if genotype 1 AND
  • ONE of the following: (A) The patient is treatment naive OR (B) The patient was previously treated with peginterferon and ribavirin with or without an HCV protease inhibitor OR (C) The patient has decompensated cirrhosis AND
  • The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection