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Mavyret — Cigna

Genotype 1 or 4 Hepatitis C Virus in a patient with renal impairment (eGFR < 30 mL/min or ESRD), pediatric patient age ≥ 3 years and < 18 years – new start

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