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

Hepatitis C genotype 6

Preferred products

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

Initial criteria

  • The patient has a diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6 AND
  • ONE of the following: the patient is treatment naive OR the patient was previously treated with ONLY peg-interferon and ribavirin with or without an HCV protease inhibitor OR the patient has decompensated cirrhosis AND
  • If the patient has an FDA labeled indication, then ONE of the following: the patient’s age is within FDA labeling for the requested indication OR there is support for the use of the requested agent for the patient’s age for the requested indication AND
  • The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection AND if positive, 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, then ONE of the following: requested agent is a preferred agent OR patient has been treated with requested non-preferred agent in past 30 days OR patient has intolerance/hypersensitivity or contraindication to ALL preferred agent(s) OR there is support for use of non-preferred agent over preferred agent(s) AND
  • ONE of the following: prescriber is a specialist (e.g., gastroenterologist, hepatologist, or infectious disease) or has consulted with a specialist OR all of the following: treatment naive, without or with compensated cirrhosis, requested agent supported in AASLD guidelines for simplified treatment, and patient meets all 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 1 (FDA labeling) or Table 2 (AASLD/IDSA guidelines for decompensated cirrhosis) AND
  • The requested length of therapy does NOT exceed the length of therapy noted in Table 1 or Table 2

Approval duration

up to duration of treatment per Tables 1 or 2