Mavyret — Medical Mutual
HCV with renal impairment (eGFR < 30 mL/min or ESRD)
Preferred products
- Epclusa (brand)
- Harvoni (brand)
- Vosevi
- Zepatier
Initial criteria
- Patient must meet the respective standard Hepatitis C Prior Authorization Policy criteria
- Patient must have tried one Preferred Product unless exception applies
- Non-preferred products require exception criteria approval
Reauthorization criteria
- Refer to the respective standard Hepatitis C PA Policy criteria or Mavyret PA for PSM Policy for continuation
Approval duration
per standard Hepatitis C PA Policy