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Sovaldi (sofosbuvir) — Blue Cross Blue Shield of Illinois

pediatric hepatocellular carcinoma secondary to chronic hepatitis C genotype 2 or 3

Preferred products

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

Initial criteria

  • One of: (A) Pediatric patient with diagnosis of hepatocellular carcinoma secondary to chronic hepatitis C genotype 2 or 3 AND (if FDA labeled indication) one of: (1) age within FDA labeling OR (2) support for use at patient’s age for indication OR (B) Pediatric patient with diagnosis of hepatitis C genotype 2 or 3 AND all of the following:
  • If FDA labeled indication, one of: (A) patient’s age within labeling OR (B) support for use at patient’s age for indication AND
  • One of: (A) request is for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR (B) patient currently treated and stable on non-preferred agent [chart notes required]