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Vosevi — Blue Cross Blue Shield of Alabama

Hepatitis C genotypes 1-6

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
  • If the patient has an FDA labeled indication, then ONE of the following: • The patient’s age is within FDA labeling for the requested agent for the requested indication OR • There is support for the use of the requested agent for the patient’s age for the requested indication
  • The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection
  • If HBV screening was positive, the prescriber will monitor for HBV flare-up or reactivation during and after treatment
  • If the client has preferred agent(s) for the patient’s specific factors (e.g., age, genotype, cirrhosis status, treatment naïve vs experienced, previous treatment), then ONE of the following: • The requested agent is a preferred agent OR • The patient has been treated with the requested non-preferred agent in the past 30 days OR • The patient has an intolerance or hypersensitivity to ALL preferred agents OR • The patient has an FDA labeled contraindication to ALL preferred agents OR • There is support for the use of the requested non-preferred agent over the preferred agent(s)
  • ONE of the following: • The prescriber is a gastroenterologist, hepatologist, or infectious disease specialist, or has consulted with one OR • ALL of the following: – The patient is treatment naïve – The patient does not have cirrhosis or has compensated cirrhosis – The requested agent is supported in AASLD guidelines for simplified treatment – The patient meets all qualifications for simplified treatment
  • The patient has not been previously treated with the requested agent
  • The patient does not have any FDA labeled contraindications to the requested agent
  • The patient meets all requirements and will use the requested agent in a treatment regimen noted in FDA labeling (Tables 5, 6, or 7)
  • The requested length of therapy does not exceed the FDA labeled duration for the patient’s regimen

Approval duration

up to treatment duration per FDA labeling