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