Hepatitis C, Direct-Acting Antivirals

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Current Drug Use Criteria New Drug Evaluation
glecaprevir/pibrentasvir MAVYRET TABLET Y PA Document  
sofosbuvir/velpatas/voxilaprev VOSEVI TABLET Y PA Document  
sofosbuvir/velpatasvir SOFOSBUVIR-VELPATASVIR TABLET Y PA Document  
elbasvir/grazoprevir ZEPATIER TABLET N PA Document  
glecaprevir/pibrentasvir MAVYRET PELET PACK N PA Document  
ledipasvir/sofosbuvir HARVONI PELET PACK N PA Document  
ledipasvir/sofosbuvir HARVONI TABLET N PA Document  
ledipasvir/sofosbuvir LEDIPASVIR-SOFOSBUVIR TABLET N PA Document  
ombita/paritap/riton/dasabuvir VIEKIRA PAK TAB DS PK N PA Document Mar 26, 2015
sofosbuvir SOVALDI PELET PACK N PA Document  
sofosbuvir SOVALDI TABLET N PA Document Jan 30, 2014
sofosbuvir/velpatasvir EPCLUSA PELET PACK N PA Document  
sofosbuvir/velpatasvir EPCLUSA TABLET N PA Document