Vosevi (sofosbuvir/velpatasvir/voxilaprevir) — Blue Cross Blue Shield of Alabama

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Harvoni (ledipasvir/sofosbuvir)
• Ledipasvir/Sofosbuvir
• Sofosbuvir/Velpatasvir
• Mavyret (glecaprevir/pibrentasvir)

Initial criteria

• The patient has a diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6
• AND if genotype 1, the prescriber has provided the patient’s subtype
• AND the patient is NOT treatment naive
• AND the patient has NOT been previously treated with the requested agent
• AND if the patient has an FDA labeled indication, then ONE of the following: the patient's age is within FDA labeling OR there is support for use for the requested indication and age
• AND the prescriber has screened the patient for current or prior hepatitis B virus infection
• AND if HBV screening was positive, the prescriber will monitor for HBV flare-up or reactivation during and after treatment
• AND if the client has preferred agent(s) for the patient’s specific factors, then ONE of the following: the patient has been treated with the requested non-preferred agent in the past 30 days OR has intolerance/hypersensitivity to ALL preferred agents OR has contraindication to ALL preferred agents OR there is support for use of the requested agent over preferred agent(s)
• AND ONE of the following: the prescriber is a specialist (gastroenterologist, hepatologist, or infectious disease) or has consulted one OR ALL of the following are true: patient is treatment naive AND patient does not have cirrhosis or has compensated cirrhosis AND the requested agent is supported in AASLD simplified treatment guidelines AND patient meets all AASLD simplified treatment qualifications
• AND the patient does NOT have FDA labeled contraindications to the requested agent
• AND the patient meets all requirements and will use the requested agent in a regimen noted in Table 9
• AND the requested therapy duration does not exceed that noted in Table 9

Approval duration

up to duration of treatment per Table 9