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Mavyret — Medica

genotype 2 chronic HCV

Preferred products

  • Epclusa (brand)
  • Harvoni (brand)
  • Vosevi
  • Zepatier

Initial criteria

  • For genotype 1 adult new start: if treatment‑naïve, not approved; offer to review for Epclusa (brand), Harvoni (brand), or Zepatier using respective Hepatitis C PA Policy criteria.
  • Approve if BOTH: (i) patient meets Hepatitis C – Mavyret PA for PSM Policy criteria; AND (ii) meets ONE of: (a) prior treatment with pegylated interferon/ribavirin, Incivek, Olysio, or Victrelis AND failed Epclusa (brand or generic), Harvoni (brand or generic), or Zepatier (documented non‑SVR); OR (b) prior treatment with Daklinza, Epclusa (brand or generic), Harvoni (brand or generic), or Zepatier AND failed Vosevi (documented non‑SVR); OR (c) prior treatment with Sovaldi + ribavirin ± pegylated interferon/interferon OR Sovaldi + Olysio.
  • For genotype 1 pediatric new start: if treatment‑naïve, not approved; offer to review for Epclusa (brand) or Harvoni (brand). Approve if meets Hepatitis C – Mavyret PA for PSM Policy criteria AND ONE of: (a) prior pegylated interferon/ribavirin ± Incivek/Olysio/Victrelis AND failed Epclusa (brand or generic) or Harvoni (brand or generic) (documented non‑SVR); OR (b) prior Daklinza, Epclusa (brand or generic), Harvoni (brand or generic), or Zepatier; OR (c) prior Sovaldi + ribavirin ± pegylated interferon/interferon OR Sovaldi + Olysio.
  • For genotype 2 chronic HCV new start: if treatment‑naïve, not approved; offer to review for Epclusa (brand). Approve if meets Hepatitis C – Mavyret PA for PSM Policy criteria AND ONE of: (a) prior pegylated interferon/ribavirin AND failed Epclusa (brand or generic) (non‑SVR documented); OR (b) prior Sovaldi + ribavirin ± pegylated interferon/interferon.
  • For genotype 3 pediatric new start: if treatment‑naïve, not approved; offer to review for Epclusa (brand). Approve if meets standard Hepatitis C – Mavyret PA for PSM criteria AND ONE of: (a) prior pegylated interferon/ribavirin AND failed Epclusa (brand or generic) (non‑SVR documented); OR (b) other specified prior regimen as noted.

Approval duration

as specified in the Hepatitis C – Mavyret PA for PSM Policy