Vosevi (sofosbuvir/velpatasvir/voxilaprevir) — Blue Cross Blue Shield of Kansas

Preferred products

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

Initial criteria

• The patient has a diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6 AND
• If genotype 1, prescriber has provided subtype AND
• The patient is NOT treatment naive AND
• The patient has NOT been previously treated with the requested agent AND
• If FDA labeled indication, ONE of: (A) Patient’s age within labeling OR (B) Support for use in patient’s age AND
• Prescriber has screened for HBV infection AND if positive will monitor for HBV flare-up/reactivation AND
• If client has preferred agent(s), ONE of: (A) Patient treated with requested non-preferred agent in past 30 days OR (B) Intolerance/hypersensitivity to ALL preferred agent(s) OR (C) FDA labeled contraindication to ALL preferred agents OR (D) Clinical information supports non-preferred over preferred AND
• ONE of: (A) Prescriber is specialist or has consulted specialist OR (B) ALL of the following: patient is treatment naive; no or compensated cirrhosis; requested agent supported by AASLD guidelines; patient meets 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 treatment regimen noted in Table 9 AND
• The requested length of therapy does NOT exceed Table 9 duration

Approval duration

Up to duration in Table 9