CurrentColorado Rocky Mountain Health PlansPolicy N/A

Mavyret (glecaprevir/pibrentasvir) prior authorization

Defines prior authorization and coverage criteria for Mavyret for treatment of acute and chronic hepatitis C virus (HCV) infections for applicable members; intended for providers submitting prior authorization requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMavyret (glecaprevir/pibrentasvir) prior authorization

Policy CodePolicy N/A

Change TypeCriteria additions and authorization duration updates

Effective DateJan 1, 2026

Next Review DateJul 1, 2025

Key ActionObtain prior authorization — approvals issued for 8 weeks for acute treatment‑naïve patients and 12 months for chronic HCV treatment.

SourceLink

POLICY UPDATE CHANGES

Authorization duration for chronic HCV infection updated to 12 months.

Coverage criteria for acute HCV infection in treatment-naïve patients added with an 8-week authorization.

Criteria reorganized to combine chronic HCV treatment-experienced patients and transplant recipients into one section and simplify pangenotypic and cirrhosis status criteria.

8 weeksauthorization length for acute, treatment-naïve HCV

12 monthsauthorization length for chronic HCV

≥3 yrsindicated patient age

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Coverage Criteria for Mavyret

inv-01: Acute hepatitis C — Initial therapy

Covered when ALL of the following are met:

Acute HCV treatment (treatment-naïve): 1) Diagnosis of acute hepatitis C infection; 2) Patient is not receiving Mavyret in combination with another hepatitis C virus (HCV) direct-acting antiviral agent (e.g., sofosbuvir/velpatasvir, ledipasvir/sofosbuvir, sofosbuvir, elbasvir/grazoprevir); 3) Patient is treatment-naïve

Authorization will be issued for 8 weeks

inv-02: Chronic hepatitis C — Initial therapy

Covered when ALL of the following are met:

Chronic HCV treatment: 1) Diagnosis of chronic hepatitis C infection; 2) Patient is not receiving Mavyret in combination with another hepatitis C virus (HCV) direct-acting antiviral agent (e.g., sofosbuvir/velpatasvir, ledipasvir/sofosbuvir, sofosbuvir, elbasvir/grazoprevir); 3) Patient is treatment-naïve

Authorization will be issued for 12 months

Use of Mavyret in combination with another hepatitis C virus (HCV) direct-acting antiviral (DAA) agent is excluded from coverage. Examples of excluded concomitant HCV DAAs include Epclusa (sofosbuvir/velpatasvir), Harvoni (ledipasvir/sofosbuvir), Sovaldi (sofosbuvir), and Zepatier (elbasvir/grazoprevir).

Initial Therapy Details

inv-10: Initial therapy

Initial coverage is provided when ALL of the applicable criteria below are met.

Initial therapy - acute (treatment-naïve): Diagnosis of acute hepatitis C infection AND patient is not receiving Mavyret with another HCV direct-acting antiviral agent AND patient is treatment-naïve

Authorization 8 weeks

Initial therapy - chronic: Diagnosis of chronic hepatitis C infection AND patient is not receiving Mavyret with another HCV direct-acting antiviral agent AND patient is treatment-naïve

Authorization 12 months

Reauthorization and Continuation Rules

inv-11: Reauthorization rules

Reauthorization and continuation are permitted under the following conditions.

Reauthorization: UnitedHealthcare may approve initial and reauthorization requests based on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic; supply limits and medical necessity reviews may apply

Use of automated approval and re-approval processes varies by program and/or therapeutic class

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for initiation of therapy. Approval durations differ by indication: acute hepatitis C approvals are issued for 8 weeks; chronic hepatitis C approvals are issued for 12 months for reauthorization/continuation when criteria met.

Acute treatment approval duration: 8 weeks
Chronic treatment approval duration: 12 months

Note

Automated Approval / Utilization Management

Automated approval and utilization management processes may be used. Authorization and reauthorization can be granted based solely on previous claim/medication history, diagnosis (ICD-10) codes, and/or claim logic. Supply limits and other utilization controls (e.g., quantity limits) may apply.

Approvals may be automated using prior claims/medication history and ICD-10 codes
Supply limits may be enforced

Background

Mavyret is a fixed-dose combination of glecaprevir (an NS3/4A protease inhibitor) and pibrentasvir (an NS5A inhibitor) indicated for the treatment of adults and pediatric patients aged 3 years and older with acute or chronic hepatitis C virus (HCV) infection. It is pangenotypic (GT1–6) and may be used in patients with compensated cirrhosis (Child‑Pugh A) and certain treatment‑experienced genotype 1 patients per the product labeling.

Definitions and Key Terms

Compensated cirrhosis (Child-Pugh A)

DefinitionCirrhosis classification indicating preserved hepatic function as referenced in the product indication (Child-Pugh A).

Age range in indicationIncluded in indication for Mavyret: patients aged 3 years and older.

Relevance to coveragePolicy allows treatment with Mavyret in patients with compensated cirrhosis (Child-Pugh A).

Step Therapy / Automated Approval Logic

Step	Description
1
UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim or medication history, diagnosis codes (ICD-10), and/or claim logic; use of automated approval and re-approval processes varies by program and therapeutic class. Supply limits and medical necessity reviews may apply.

Quantity Limits

Mavyret (glecaprevir/pibrentasvir) — supply/limits

Supply limitsSupply limits may be in place for Mavyret (glecaprevir/pibrentasvir).

Automated approvalsUnitedHealthcare may approve initial and reauthorization based on prior claim/medication history, diagnosis codes, and/or claim logic; automated processes vary by program.

Medical necessity reviewsMedical necessity reviews may apply as part of utilization management for Mavyret.