Ledipasvir/Sofosbuvir — Blue Cross Blue Shield of Montana

Initial criteria

• Meets the general module clinical criteria above
• Treatment recommendations per FDA labeling (Table 3) or AASLD guidelines (Table 4) for listed genotypes 1, 4, 5, 6, treatment-naive or experienced, with or without compensated or decompensated cirrhosis, and ribavirin use as appropriate

Approval duration

up to 24 weeks per treatment regimen