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Viekira Pak™ Added to the Medi-Cal Contract Drugs List

June 12, 2015

Effective for dates of service on or after July 1, 2015, Viekira Pak (ombitasvir/paritaprevir/ritonavir and dasabuvir) is on the Medi-Cal Contract Drugs List for the treatment of chronic hepatitis C, subject to the following Code I restrictions:

Requires a Treatment Authorization Request (TAR). Restricted to use in the treatment of chronic Hepatitis C Virus (HCV) infection in adults (≥18 years of age). Also restricted to 1) a maximum quantity of 112 tablets per dispensing; and 2) duration of therapy lasting up to 12 or 24 weeks from the dispensing date of the first prescription.

Providers are also reminded to provide documentation of baseline HCV-RNA level and HCV genotype. In addition, when applicable, providers must document relevant clinical information (for instance, failure of prior treatment, presence of cirrhosis, etc.) in support of medical necessity for duration of therapy. Failure to submit supporting documentation may delay authorization of the TAR.

Updated provider manual sections will be released in a future Medi-Cal Update.