Ledipasvir/Sofosbuvir — Blue Cross Blue Shield of Kansas
chronic hepatitis C virus (HCV) infection genotypes 1, 4, 5, or 6
Preferred products
- Harvoni
- Ledipasvir/Sofosbuvir
- Epclusa
- Sofosbuvir/Velpatasvir
- Mavyret
- Vosevi
Initial criteria
- Diagnosis of hepatitis C genotype 1, 4, 5, or 6
- Patient age ≥ 3 years
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient will use the requested agent in a treatment regimen noted in Table 3 (FDA labeling) or Table 4 (AASLD/IDSA guidelines for decompensated cirrhosis)
- Requested length of therapy does NOT exceed the corresponding regimen duration per Table 3 or Table 4
Approval duration
up to duration of treatment per Table 3 or 4