Direct-acting Antivirals for Hepatitis C

Coverage Decision

Direct-acting antivirals for hepatitis C require prior authorization (F252-112-000) for coverage. Coverage criteria include, but are not limited to:

  • Hepatitis C is an accepted condition
  • Patient has evidence of active chronic hepatitis C infection
  • Drug is prescribed consistent with FDA labeling

Preferred agents in this drug class:

  • Glecaprevir/pibrentasvir (Mavyret®).
  • Sofosbuvir/velpatasvir (Epclusa®) – for decompensated cirrhosis.
  • Sofosbuvir/velpatasvir/voxilaprevir (Vosevi®) – for patients who have failed previous antiviral treatment (see FDA labeling).