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

hepatitis C genotype 6

Preferred products

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

Initial criteria

  • Diagnosis of hepatitis C genotype 1–6 AND
  • If FDA labeled indication, then one of: (A) patient’s age within FDA labeling OR (B) there is support for use at patient’s age for indication AND
  • Prescriber has screened for current or prior hepatitis B viral (HBV) infection AND
  • If HBV screening positive, prescriber will monitor for HBV flare-up or reactivation during and after treatment AND
  • If client has preferred agent(s), then 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) Requested agent is preferred for patient’s factors OR (C) Patient treated with non-preferred agent in past 30 days OR (D) Patient currently stable on non-preferred agent [chart notes required] OR (E) Tried and inadequate response to all preferred agent(s) [chart notes required] OR (F) All preferred agent(s) discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR (G) Intolerance or hypersensitivity to all preferred agent(s) [chart notes required] OR (H) FDA labeled contraindication to all preferred agent(s) [chart notes required] OR (I) All preferred agent(s) expected to be ineffective, cause barrier to adherence, worsen comorbidity, or cause harm [chart notes required] OR (J) All preferred agent(s) not in best interest based on medical necessity [chart notes required] OR (K) Tried another drug in same class as all preferred agents, discontinued due to inefficacy or adverse event [chart notes required] OR (L) Prescriber provides rationale supporting use of requested non-preferred agent
  • Prescriber is a specialist (gastroenterologist, hepatologist, infectious disease) OR meets criteria for simplified AASLD treatment protocol (treatment naïve, no cirrhosis or compensated cirrhosis, guideline supported agent) AND meets simplified-treatment eligibility (adults with chronic HCV infection, any genotype, not previously treated, without cirrhosis or with compensated cirrhosis [Child-Pugh A]) AND excludes patients with criteria listed (prior HCV treatment, HBV surface antigen positivity, decompensated cirrhosis, end-stage renal disease, pregnancy, HCC, prior liver transplant)
  • Patient has not been previously treated with requested agent AND
  • No FDA labeled contraindications to requested agent AND
  • Meets all regimen requirements per Table 5 and requested therapy duration does not exceed FDA labeled duration

Approval duration

6 months (BCBSIL, BCBSMT) or up to FDA-labeled treatment duration (others; at least 12 weeks BCBSNM)