Mavyret — Medical Mutual

Initial criteria

• Patient age ≥ 3 years
• Prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or a liver transplant physician
• One of the following:
• NS5A-Experienced, NS3/4-Naïve: No cirrhosis or compensated cirrhosis (Child-Pugh A) AND prior null/partial/relapse with Daklinza, sofosbuvir/velpatasvir, or ledipasvir/sofosbuvir AND no prior treatment with NS3/4A inhibitor(s). Approval: 16 weeks
• NS3/4-Experienced, NS5A-Naïve: No cirrhosis or compensated cirrhosis AND no prior treatment with NS5A-containing regimens AND prior null/partial/relapse with Olysio, Victrelis, or Incivek. Approval: 12 weeks
• PegIFN/Interferon, Ribavirin, Sovaldi-Experienced, no cirrhosis, relapse/partial/null. Approval: 8 weeks
• PegIFN/Interferon, Ribavirin, Sovaldi-Experienced, compensated cirrhosis, relapse/partial/null. Approval: 12 weeks

Approval duration

8-16 weeks