Ledipasvir/Sofosbuvir — Blue Cross Blue Shield of Kansas

Hepatitis C genotype 4

Preferred products

The patient has a diagnosis of hepatitis C genotype 1, 4, 5, or 6 AND
The prescriber has provided the patient’s baseline HCV RNA level if genotype 1 AND
ONE of the following: treatment naive OR previously treated with peg-interferon and ribavirin with or without an HCV protease inhibitor OR has decompensated cirrhosis AND
The prescriber has screened for current or prior HBV infection AND if positive, will monitor for HBV flare or reactivation AND
If the patient has an FDA labeled indication, then age is within labeling for the requested indication OR there is support for use in the patient’s age for that indication AND
If the client has preferred agent(s), then ONE of the following: requested agent is preferred OR patient has been treated with non-preferred agent in past 30 days OR patient has intolerance, hypersensitivity, or contraindication to ALL preferred agents OR there is support for use of non-preferred agent over preferred agents AND
ONE of the following: prescriber is specialist (gastroenterologist, hepatologist, infectious disease) or has consulted one OR all of the following: treatment naive, no or compensated cirrhosis, requested agent supported in AASLD guidelines for simplified treatment, meets all simplified treatment qualifications AND
The patient does NOT have FDA labeled contraindications to requested agent AND
The patient meets requirements and will use agent in regimen in Table 1 or Table 2 AND therapy length does not exceed lengths in Table 1 or Table 2

up to duration of treatment per Tables 1 or 2