Sovaldi — Blue Cross Blue Shield of Montana

Initial criteria

• BOTH of the following:
• 1. The requested length of therapy does NOT exceed the length of therapy noted in Table 6 or 7 (FDA labeling) for the patient’s treatment regimen AND
• 2. ONE of the following:
• A. The requested quantity (dose) does NOT exceed the program quantity limit OR
• B. The requested agent is Sovaldi 200 mg oral pellets AND BOTH of the following:
• 1. The requested quantity (dose) does NOT exceed 2 packets daily AND
• 2. There is support for why the patient cannot take 1 tablet of Sovaldi 400 mg strength OR
• C. The requested agent is Sovaldi 200 mg tablets AND BOTH of the following:
• 1. The requested quantity (dose) does NOT exceed 2 tablets daily AND
• 2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit

Approval duration

BCBSIL: 12 months; other plans: up to duration per Table 6 or 7