Ledipasvir/Sofosbuvir — Blue Cross Blue Shield of Illinois

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Mavyret (glecaprevir/pibrentasvir)

Initial criteria

• Patient has intolerance, hypersensitivity, or contraindication to BOTH Epclusa and Mavyret OR BOTH Epclusa and Mavyret are expected to be ineffective or not in best interest OR there is clinical support for requested agent over BOTH Epclusa and Mavyret [chart notes required]
• Patient is treatment naive OR treatment experienced with ONLY peg‑interferon and ribavirin OR adult with diagnosis of hepatocellular carcinoma secondary to chronic hepatitis C genotype 1–4 OR adult with hepatitis C genotype 1–4 meeting listed treatment experience criteria
• If plan has preferred agents for specific patient factors (e.g., genotype, cirrhosis status, treatment experience): patient meets one of the following: request is for BCBS IL Fully Insured/ASO Cost/BBF/HIM/Non‑ERISA ASO members; previously treated with requested non‑preferred agent in past 30 days; currently stable on requested non‑preferred agent; tried and failed ALL preferred agents; discontinued ALL preferred agents due to lack of efficacy or adverse event; intolerance/hypersensitivity/contraindication to ALL preferred agents; ALL preferred agents expected to be ineffective or not in patient’s best interest; or support provided for use of requested agent over preferred agent(s) [chart notes required]
• Prescriber has screened for current or prior hepatitis B viral (HBV) infection and will monitor for reactivation if positive
• Prescriber is a specialist in gastroenterology, hepatology, infectious disease, or has consulted such a specialist OR patient is treatment‑naive without cirrhosis or with compensated cirrhosis and meets AASLD simplified‑treatment qualifications and requirements including absence of HBV surface antigen positivity, decompensated cirrhosis, pregnancy, prior liver transplant or hepatocellular carcinoma
• Patient has no FDA‑labeled contraindications to requested agent
• Requested agent will be used per FDA‑labeled regimen and duration (Tables 6 and 7 per genotype)

Approval duration

6 months or per FDA‑labeled regimen duration; 12 months for Ohio Fully Insured or HIM Shop plans