Sovaldi — Blue Cross Blue Shield of New Mexico
Hepatitis C virus infection (genotypes 1–4, adult and pediatric per FDA labeling)
Initial criteria
- 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
- 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; Others: up to duration per Table 6 or 7 (12–48 weeks per FDA labeling)