CurrentCignaPolicy IP0737

Mavyret Prior Authorization Policy

Defines clinical coverage, approval durations, prescriber requirements, and exclusions for Mavyret for treatment of chronic and recurrent hepatitis C across specified genotypes; applies to Cigna members in North Carolina.

Policy Summary

PayerCigna

PolicyMavyret Prior Authorization Policy

Policy CodePolicy IP0737

Change TypeNew FDA-approved indication added

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain prior authorization and ensure prescription is written by or in consultation with an authorized transplant-affiliated specialist.

SourceLink

POLICY UPDATE CHANGES

A new FDA-Approved Indication was added allowing Mavyret approval for 8 weeks in patients meeting criteria for acute HCV genotypes 1–6.

8 weeksnew acute HCV duration

12 weekspost-transplant duration

≥3 yrsmin age (post-transplant)

≥18 yrsmin age (genotype unknown)

3explicit exclusions

Coverage Criteria for Mavyret (glecaprevir/pibrentasvir)

Chronic HCV (Genotype Unknown/Undetermined)

Approve when ALL of the following are met:

Chronic HCV genotype unknown/undetermined: Patient is >= 18 years of age; AND Patient meets ONE of the following (i or ii): (i) patient does not have cirrhosis; OR (ii) patient has compensated cirrhosis; AND Patient has not previously been treated for hepatitis C virus; AND Patient does not have hepatitis B virus; AND Patient is not pregnant; AND Patient does not have hepatocellular carcinoma; AND Patient has not had a liver transplantation; AND The medication will be prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or a liver transplant physician.age >= 18

Applies to genotype unknown/undetermined

Recurrent HCV Post-Liver Transplantation

Approve when ALL of the following are met:

Recurrent HCV post-liver transplant: Patient is >= 3 years of age; AND Patient has recurrent HCV after a liver transplantation; AND The medication is prescribed by or in consultation with one of the following prescribers who is affiliated with a transplant center: gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician.

Policy Summary

PayerCigna

PolicyMavyret Prior Authorization Policy

Policy CodePolicy IP0737

Change TypeNew FDA-approved indication added

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain prior authorization and ensure prescription is written by or in consultation with an authorized transplant-affiliated specialist.

SourceLink

On This Page

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Coding and Age Minimums

inv-07: Minimum age for recurrent post-transplant approval

Minimum agePatient must be at least 3 years of age for recurrent HCV post-liver transplant approval

Indication-specific noteApplies to recurrent HCV after liver transplantation for genotypes 1–6; approval duration is 12 weeks when criteria met

Prescriber requirementMedication must be prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician affiliated with a transplant center

inv-08: Minimum age for genotype unknown/undetermined approval

Minimum agePatient must be at least 18 years of age for chronic HCV with genotype unknown/undetermined

Additional clinical requirementsPatient must be treatment‑naive, not pregnant, not co‑infected with hepatitis B, not have hepatocellular carcinoma, not have had liver transplantation, and have no decompensated cirrhosis (no cirrhosis or compensated cirrhosis allowed)

Prescriber requirementMedication must be prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician

Prescriber Requirements, Authorization, and Denial Conditions

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approvals are issued for specified durations based on indication (for example, 12 weeks for recurrent post-liver transplant HCV). Prescriptions must be written by or in consultation with an authorized specialist affiliated with a transplant center.

Prior authorization required; approval durations depend on indication (e.g., 12 weeks for recurrent HCV post-liver transplant).
Prescriptions must be written by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or liver transplant physician who is affiliated with a transplant center.

Denial Risk

Denial Triggers / Not Medically Necessary Uses

Requests for Mavyret should be denied when the use is listed as not medically necessary or contraindicated per policy. Common denial triggers include moderate or severe hepatic impairment (Child-Pugh Class B or C), use in combination with other direct-acting antivirals, and use in pediatric patients under 3 years of age.

Contraindicated: Hepatic impairment Child-Pugh Class B or C — deny.
Not covered: Combination therapy with any other direct-acting antivirals — deny.
Not covered: Pediatric patients < 3 years of age — deny.

OpenPayer

Mavyret Prior Authorization Policy

Coverage Criteria for Mavyret (glecaprevir/pibrentasvir)

Coding and Age Minimums

Prescriber Requirements, Authorization, and Denial Conditions

Background on Mavyret and Policy Scope

Definitions and Clinical Terms