Sovaldi — Blue Cross Blue Shield of Kansas

Preferred products

• Epclusa
• Harvoni
• Ledipasvir/Sofosbuvir
• Sofosbuvir/Velpatasvir
• Mavyret
• Vosevi

Initial criteria

• Patient has a diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6
• If FDA labeled indication, patient age is within labeling OR there is support for use at that age
• Prescriber has screened patient for current or prior hepatitis B infection
• If HBV positive current or prior infection, prescriber will monitor for HBV flare/reactivation during and after treatment
• If preferred agents exist for the patient's genotype and other factors, then ONE of the following applies:
• • Requested agent is a preferred agent, OR
• • Patient has been treated with requested non-preferred agent in the past 30 days, OR
• • Patient has intolerance or hypersensitivity to ALL preferred agents, OR
• • Patient has FDA labeled contraindication to ALL preferred agents, OR
• • There is support for use of requested non-preferred agent over preferred agents
• Prescriber is a specialist (gastroenterologist, hepatologist, or infectious disease) OR patient meets all simplified treatment qualifications per AASLD
• Patient has not been previously treated with requested agent
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Requested length of therapy does NOT exceed labeling

Approval duration

up to duration of treatment per Table 5