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:

This Medication is Not Approvable for the following condition(s):



  • Patient has a diagnosis of Hepatitis C, Genotype 4 AND
  • Patient does not have cirrhosis.  Not recommended for use in patients with moderate to severe hepatic impairment (Child-Pugh B or C)
  • 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.
  • Any condition not listed above as an approved indication.  Not approvable for other than Genotype 4
  • Genotype 4:  Two tablets once every morning (fixed dose tablet contains ombitasvir 12. mg, paritaprevir 75 mg, and ritonavir 50 mg)

Last review date: July 24, 2016

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