Mavyret — Cigna
Genotype 1 Chronic Hepatitis C Virus Adults (age ≥ 18 years)
Preferred products
- Epclusa (brand)
- Harvoni (brand)
- Vosevi (brand)
- Zepatier
Initial criteria
- Approve for acute HCV genotypes 1–6 when patient meets Hepatitis C – Mavyret PA for PSM Policy criteria
- For genotype 1 chronic HCV adult new starts: if treatment-naïve, Mavyret is not approved; offer to review for Epclusa (brand only), Harvoni (brand only), or Zepatier using respective Hepatitis C PA Policy criteria
- Otherwise, approve if patient meets both: (i) Hepatitis C – Mavyret PA for PSM Policy criteria AND (ii) one of the following:
- a) Previously treated with pegylated interferon/ribavirin, Incivek, Olysio, or Victrelis AND completed a course of Epclusa, Harvoni, or Zepatier without achieving sustained viral response (documentation required); OR
- b) Previously treated with Daklinza, Epclusa, Harvoni, or Zepatier AND completed a course of Vosevi without achieving sustained viral response (documentation required); OR
- c) Previously treated with Sovaldi + ribavirin ± pegylated interferon/interferon OR Sovaldi + Olysio
- If patient meets criteria (2Bi, 2Biia) but not 2Biia(1): offer to review for Epclusa (brand only), Harvoni (brand only)
Approval duration
per Hepatitis C – Mavyret PA for PSM Policy