Vosevi — Blue Cross Blue Shield of Illinois

Preferred products

• Mavyret
• Epclusa

Initial criteria

• If screening for HBV was positive for current or prior infection, prescriber will monitor for HBV flare-up or reactivation during and after treatment
• 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 using the requested agent for the patient’s age
• If preferred agents exist for the patient’s specific factors (age, genotype, cirrhosis status, treatment history), then ONE of the following: (A) The request is for a BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR (B) The requested agent is a preferred agent OR (C) Patient has been treated with the requested non-preferred agent in the past 30 days OR (D) Patient is currently stable on the requested non-preferred agent [chart notes required] OR (E) Patient has tried and had an inadequate response to ALL preferred agents [chart notes required] OR (F) ALL preferred agents discontinued due to lack of efficacy or adverse event [chart notes required] OR (G) Patient has intolerance or hypersensitivity to ALL preferred agents [chart notes required] OR (H) Patient has contraindication to ALL preferred agents OR (I) ALL preferred agents expected to be ineffective or may cause adherence barrier, worsen comorbidity, or cause adverse reaction [chart notes required] OR (J) ALL preferred agents are not in best interest of patient based on medical necessity [chart notes required] OR (K) Patient has tried another drug in same pharmacologic class as preferred agents and it was discontinued due to lack of efficacy or adverse event [chart notes required] OR (L) There is support for use of non-preferred agent over preferred agents
• ONE of the following: (A) Prescriber is a specialist in gastroenterology, hepatology, or infectious disease OR (B) ALL of the following: (1) Patient is treatment naive AND (2) Patient has no cirrhosis or compensated cirrhosis AND (3) Requested agent is supported in AASLD guidelines for simplified treatment AND (4) Patient meets all qualifications for simplified HCV treatment
• Patients Eligible for Simplified HCV Treatment: Adults (age ≥18 years) with chronic HCV infection (any genotype), treatment naive, without cirrhosis or with compensated cirrhosis (Child-Pugh A)
• Patients Excluded from Simplified HCV Treatment: previously received HCV treatment, hepatitis B surface antigen-positive, compensated cirrhosis with end-stage renal disease (eGFR < 30 mL/min/m^2), decompensated cirrhosis (Child-Pugh ≥7), current pregnancy, known or suspected hepatocellular carcinoma, prior liver transplantation
• Patient does NOT have any FDA labeled contraindications to requested agent
• Requested agent will be used in a regimen consistent with Table 3 (FDA labeling) or Table 4 (AASLD guidelines for decompensated cirrhosis)
• Requested length of therapy does NOT exceed recommended duration per Table 3 or 4

Approval duration

6 months (BCBSIL and BCBSMT); otherwise up to treatment duration per Table 3 or 4 (≥12 weeks for BCBSNM)