Mavyret — Medica
acute or chronic hepatitis C virus (HCV) genotype 1 through 6 per exception criteria
Preferred products
- Epclusa (brand)
- Harvoni (brand)
- Vosevi
- Zepatier
Initial criteria
- Genotype 1–6 Acute HCV: Approve if patient meets the Hepatitis C – Mavyret PA for PSM Policy criteria.
- Genotype 1 Chronic HCV Adults (≥18 years):
- - If treatment-naïve: Mavyret is not approved; offer to review for Epclusa (brand), Harvoni (brand), or Zepatier using respective Hepatitis C PA Policy criteria.
- - Otherwise approve if BOTH met: (i) patient has met the Mavyret PA for PSM Policy criteria; AND (ii) patient meets one of the following:
- a) Prior therapy with pegylated interferon/ribavirin, Incivek, Olysio, or Victrelis AND did not achieve SVR with Epclusa, Harvoni, or Zepatier [documentation required]; OR
- b) Prior therapy with Daklinza, Epclusa, Harvoni, or Zepatier AND did not achieve SVR with Vosevi [documentation required]; OR
- c) Prior therapy with Sovaldi + ribavirin ± pegylated interferon/interferon or Sovaldi + Olysio.
- Genotype 1 Chronic HCV Pediatric (≥3 and <18 years): similar criteria structure with Epclusa or Harvoni as preferred options if treatment‑naïve.
- Genotype 2 Chronic HCV: if treatment‑naïve not approved (review for Epclusa); or approve if met Mavyret PA for PSM criteria AND prior therapy with peginterferon/ribavirin (failed Epclusa) or Sovaldi + ribavirin ± interferon.
- Genotype 3 Chronic HCV Pediatric (≥3 and <18 years): if treatment‑naïve not approved (review for Epclusa); or approve if met Mavyret PA for PSM criteria.
Approval duration
as specified in the Hepatitis C – Mavyret PA for PSM Policy