Epclusa (sofosbuvir/velpatasvir) — Blue Cross Blue Shield of Kansas

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Harvoni (ledipasvir/sofosbuvir)
• Ledipasvir/Sofosbuvir
• Sofosbuvir/Velpatasvir
• Mavyret (glecaprevir/pibrentasvir)
• Vosevi (sofosbuvir/velpatasvir/voxilaprevir)

Initial criteria

• The patient has a diagnosis of hepatitis C genotype 1 AND
• The prescriber has provided the patient’s subtype AND
• ONE of the following: (A) The patient is treatment naive OR (B) The patient was previously treated with ONLY peg-interferon and ribavirin AND
• If the patient has an FDA labeled indication, 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 positive, the prescriber will monitor the patient for HBV flare-up/reactivation during and after treatment AND
• If client has preferred agent(s) for the patient’s specific factors, ONE of the following: (A) Patient has used requested non-preferred agent in past 30 days OR (B) Intolerance/hypersensitivity to ALL preferred agents OR (C) FDA labeled contraindication to ALL preferred agents OR (D) Support for requested non-preferred agent over preferred agent(s) AND
• ONE of the following: (A) Prescriber is a specialist (gastroenterologist, hepatologist, infectious disease) or has consulted such specialist OR (B) ALL: (1) Patient is treatment naive AND (2) No or compensated cirrhosis AND (3) Requested agent supported in AASLD guidelines for simplified treatment AND (4) Patient meets simplified treatment criteria 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 treatment regimen noted in Table 8 AND
• The requested length of therapy does NOT exceed the length of therapy in Table 8

Approval duration

Up to duration in Table 8