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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00006307401 ZEPATIER elbasvir/grazoprevir TABLET 50 mg-100 mg N Y Quantity Limit
00006307402 ZEPATIER elbasvir/grazoprevir TABLET 50 mg-100 mg N Y Quantity Limit
00074260028 MAVYRET glecaprevir/pibrentasvir PELET PACK 50 mg-20 mg N Y Quantity Limit
00074262501 MAVYRET glecaprevir/pibrentasvir TABLET 100 mg-40 mg Y Y Quantity Limit
00074262504 MAVYRET glecaprevir/pibrentasvir TABLET 100 mg-40 mg Y Y Quantity Limit
00074262528 MAVYRET glecaprevir/pibrentasvir TABLET 100 mg-40 mg Y Y Quantity Limit
00074262584 MAVYRET glecaprevir/pibrentasvir TABLET 100 mg-40 mg Y Y Quantity Limit
61958180501 HARVONI ledipasvir/sofosbuvir PELET PACK 33.75 mg-150 mg N Y Quantity Limit
61958180502 HARVONI ledipasvir/sofosbuvir PELET PACK 33.75 mg-150 mg N Y Quantity Limit
61958180401 HARVONI ledipasvir/sofosbuvir PELET PACK 45 mg-200 mg N Y Quantity Limit
61958180402 HARVONI ledipasvir/sofosbuvir PELET PACK 45 mg-200 mg N Y Quantity Limit
61958180301 HARVONI ledipasvir/sofosbuvir TABLET 45 mg-200 mg N Y Quantity Limit
61958180101 HARVONI ledipasvir/sofosbuvir TABLET 90 mg-400 mg N Y Quantity Limit
72626260101 LEDIPASVIR-SOFOSBUVIR ledipasvir/sofosbuvir TABLET 90 mg-400 mg N Y Quantity Limit
61958150401 SOVALDI sofosbuvir PELET PACK 150 mg N Y Quantity Limit
61958150402 SOVALDI sofosbuvir PELET PACK 150 mg N Y Quantity Limit
61958150501 SOVALDI sofosbuvir PELET PACK 200 mg N Y Quantity Limit
61958150502 SOVALDI sofosbuvir PELET PACK 200 mg N Y Quantity Limit
61958150301 SOVALDI sofosbuvir TABLET 200 mg N Y Quantity Limit
61958150101 SOVALDI sofosbuvir TABLET 400 mg N Y Quantity Limit
61958240101 VOSEVI sofosbuvir/velpatas/voxilaprev TABLET 400 mg-100 mg-100 mg N Y Quantity Limit
61958220501 EPCLUSA sofosbuvir/velpatasvir PELET PACK 150 mg-37.5 mg N Y Quantity Limit
61958220502 EPCLUSA sofosbuvir/velpatasvir PELET PACK 150 mg-37.5 mg N Y Quantity Limit
61958220401 EPCLUSA sofosbuvir/velpatasvir PELET PACK 200 mg-50 mg N Y Quantity Limit
61958220402 EPCLUSA sofosbuvir/velpatasvir PELET PACK 200 mg-50 mg N Y Quantity Limit
61958220301 EPCLUSA sofosbuvir/velpatasvir TABLET 200 mg-50 mg N Y Quantity Limit
61958220101 EPCLUSA sofosbuvir/velpatasvir TABLET 400 mg-100 mg N Y Quantity Limit
72626270101 SOFOSBUVIR-VELPATASVIR sofosbuvir/velpatasvir TABLET 400 mg-100 mg Y Y Quantity Limit
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