Mavyret — Cigna
Genotype 1, 4, 5, or 6 recurrent Hepatitis C Virus post-liver transplantation – new start, pediatric (age ≥ 3 years and < 18 years)
Initial criteria
- Approve for the duration specified in the Hepatitis C – Mavyret PA for PSM Policy criteria if the patient has met the Hepatitis C – Mavyret PA for PSM Policy criteria.
Reauthorization criteria
- Refer to the Hepatitis C – Mavyret PA for PSM Policy criteria.
Approval duration
duration specified in Mavyret PA for PSM Policy