Sovaldi (sofosbuvir) — Blue Cross Blue Shield of New Mexico

Preferred products

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

Initial criteria

• Patient is treatment naïve OR patient was previously treated only with peginterferon and ribavirin, with or without an HCV protease inhibitor
• Patient has an FDA approved indication for the requested agent
• Patient’s age is within FDA labeling for the requested indication OR there is support for use for the patient’s age for the requested indication
• Prescriber has screened patient for current or prior hepatitis B viral (HBV) infection
• If HBV screen is positive, prescriber will monitor for HBV flare-up or reactivation during and after treatment
• If client has preferred agents, then ONE of the following:
• • Request is for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member OR patient has been treated with the requested non‑preferred agent in the past 30 days OR patient is currently stable on requested agent OR patient has tried and had inadequate response to ALL preferred agents OR ALL preferred agents were discontinued due to lack of efficacy/effectiveness/adverse event OR patient has intolerance/hypersensitivity to ALL preferred agents OR patient has FDA labeled contraindication to ALL preferred agents OR ALL preferred agents expected to be ineffective/adherence barrier/worsen comorbid condition/adverse reaction OR ALL preferred agents not in best interest based on medical necessity OR patient tried another agent in same class as ALL preferred agents discontinued for lack of efficacy/adverse event OR there is support for use of requested non‑preferred agent over preferred agents
• Prescriber is a specialist (gastroenterologist, hepatologist, infectious disease) OR meets simplified treatment conditions per AASLD guidelines (treatment naïve, no cirrhosis or compensated cirrhosis, meets all qualifications for simplified treatment)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Requested agent used in regimen approved in Table 10 (FDA labeling) and treatment duration does not exceed recommended length

Approval duration

6 months (BCBSIL/BCBSMT); others up to regimen length (≥12 weeks for BCBSNM); 12 months for Ohio HIM/Fully Insured)