ombitasvir, paritaprevir, and ritonavir (Technivie®)
Indications for Prior Authorization:
- Treatment of chronic hepatitis C, Genotype 4 infection in patients without cirrhosis - used in combination with ribavirin. Not recommended for use in patients with moderate to severe hepatic impairment (child-Pugh B or C)
All of the following must be met as a condition for coverage:
- Patient has a diagnosis of Hepatitis C, Genotype 4
- Patient does not have cirrhosis. Not recommended for use in patients with moderate to severe hepatic impairment (Child-Pugh B or C)
- Patient must have compensated liver disease by fibroscan ultrasound or biopsy, documenting stage 2, stage 3, or stage 4
- Resistance testing must be included with the prior authorization request.
- Treatment failure associated with HCV resistance to newly developed direct-acting antiviral agents is not an uncommon occurrence and poses a substantial problem to clinicians trying to re-treat patients who have failed available interferon-free treatments.
- Trial and failure of preferred agent(s) Epclusa, Harvoni, Vosevi
This Medication is Not Approvable for the following condition(s):
- Any condition not listed above as an approved indication. Not approvable for other than Genotype 4
- Patients with Stage 0 or 1 fibrosis
- Any condition not listed above as an approved indication
- Genotype 4: Two tablets once every morning (fixed dose tablet contains ombitasvir 12. mg, paritaprevir 75 mg, and ritonavir 50 mg). Technivie is recommended to be used in combination with ribavirin.
Last review date: September 12, 2018