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Sovaldi (sofosbuvir) — Blue Cross Blue Shield of Montana

Pediatric hepatitis C genotype 2 or 3

Preferred products

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

Initial criteria

  • Patient is a pediatric patient with hepatocellular carcinoma secondary to chronic HCV genotype 2 or 3 OR pediatric patient with chronic HCV genotype 2 or 3 AND
  • If patient has an FDA labeled indication, ONE of: A. Age within labeling OR B. Supported use for age AND
  • ONE of the following: A. Request for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR B. Patient is currently being treated with the non-preferred agent and stable on it [chart notes required]