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

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: (A) The patient’s age is within FDA labeling OR (B) There is support for the use for the patient’s age AND
• The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection AND
• If HBV screening was positive, 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 (age, genotype, cirrhosis, treatment status), then ONE of the following applies: (A) The request meets plan exception criteria OR (B–M) The patient has trialed, is intolerant to, contraindicated to, or based on clinical necessity should receive the non-preferred agent [chart notes required] AND
• ONE of the following: (A) The prescriber is a specialist (gastroenterologist, hepatologist, infectious disease) OR (B) ALL of the following hold: (1) patient is treatment naive, (2) does not have or has compensated cirrhosis, (3) requested agent is supported in AASLD simplified treatment guidelines, and (4) patient meets AASLD simplified-treatment qualifications AND
• The patient does NOT have any 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 length of therapy does NOT exceed FDA-labeled duration per Table 9

Approval duration

6 months (BCBSIL, BCBSMT) or up to duration of treatment per Table 9 (other plans; at least 12 weeks for BCBSNM)