TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)

TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) 

ORAL ADMINISTRATION

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

Dosing:

• 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.