Sofosbuvir/Velpatasvir — Blue Cross Blue Shield of Illinois

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Harvoni (ledipasvir/sofosbuvir)
• Ledipasvir/Sofosbuvir
• Mavyret (glecaprevir/pibrentasvir)
• Zepatier (elbasvir/grazoprevir)

Initial criteria

• The patient has a diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6 AND
• ONE of the following: (A) The patient is treatment naive OR (B) The patient was previously treated with ONLY peginterferon and ribavirin with or without an HCV protease inhibitor OR (C) The patient has decompensated cirrhosis AND
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication OR (B) There is support for use for the patient’s age [medical records required] AND
• The prescriber has screened the patient for current or prior hepatitis B infection AND
• If screening for HBV was positive, prescriber will monitor for HBV reactivation during and after treatment AND
• If preferred agent(s) exist for patient’s specific factors, then ONE of the following: (A) The request is for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR (B) Requested agent is preferred OR (C) Patient has been treated with requested non-preferred agent in past 30 days OR (D) Patient is currently stable on requested agent OR (E) Patient has tried and had inadequate response to ALL preferred agents OR (F) Preferred agents discontinued due to lack of efficacy/adverse event OR (G) Intolerance or hypersensitivity to ALL preferred agents OR (H) Contraindication to ALL preferred agents OR (I) Preferred agents expected ineffective or cause harm/adherence issues OR (J) Preferred agents not in patient's best interest OR (K) Patient tried another drug in same class and discontinued due to lack of efficacy/adverse event OR (L) There is clinical support for use of requested non-preferred agent over preferred agents AND
• ONE of the following: (A) Prescriber is specialist (gastroenterologist, hepatologist, infectious disease) or has consulted with one OR (B) ALL of: patient is treatment naive, does NOT have or has compensated cirrhosis, requested agent supported in AASLD simplified treatment guidelines, patient meets all qualifications for simplified treatment AND
• Patient does NOT have FDA labeled contraindications AND
• Patient meets all requirements and regimen per Table 1 (FDA labeling) or Table 2 (AASLD/IDSA guidelines for decompensated cirrhosis) AND
• Requested length of therapy does NOT exceed FDA/AASLD recommended duration

Approval duration

6 months (BCBSIL/BCBSMT) or up to treatment duration as per tables (≥12 weeks for BCBSNM)