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

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Harvoni (ledipasvir/sofosbuvir)
• Sovaldi (sofosbuvir)
• Ledipasvir/Sofosbuvir
• Sofosbuvir/Velpatasvir
• Mavyret (glecaprevir/pibrentasvir)
• Zepatier (elbasvir/grazoprevir)

Initial criteria

• Patient has FDA labeled diagnosis consistent with requested agent
• Requested agent is FDA labeled for the patient’s genotype
• Patient age consistent with labeling OR supported off-label age use
• Hepatitis B viral (HBV) screening completed and appropriate monitoring in place
• Patient has no labeled contraindications
• Prescriber is specialist or meets AASLD simplified treatment criteria
• If client has preferred agent(s), step therapy exception criteria met (treatment history, intolerance, contraindication, etc.)

Approval duration

Up to treatment duration per FDA labeling