MAVYRET 40/100 mg Tablet, Film Coated

Also known as Glecaprevir And Pibrentasvir. Coverage in California (CMS PDP Region 32).

5 of 12 stand-alone Part D plans in California cover this drug on tier 5.

5 of 5 plans apply a prior authorization, step therapy or quantity limit.

200 Medicare Advantage plans in CA do cover it

Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. CA: 200 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$154.6286	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$159.2591	$14,333.3290 units	Prior authorization Quantity limit 84 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$159.2591	$14,333.3290 units	Prior authorization Quantity limit 84 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$152.0403	$13,683.6390 units	Prior authorization Quantity limit 3 per 1 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$152.0403	$13,683.6390 units	Prior authorization Quantity limit 3 per 1 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.

See coverage in all 39 regions →