Vosevi (sofosbuvir/velpatasvir/voxilaprevir) — Blue Cross Blue Shield of New Mexico

Preferred products

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

Initial criteria

• The patient has an intolerance or hypersensitivity to BOTH Epclusa and Mavyret OR
• The patient has an FDA labeled contraindication to BOTH Epclusa and Mavyret OR
• BOTH Epclusa and Mavyret are expected to be ineffective based on known clinical characteristics; OR cause significant barrier to adherence; OR worsen comorbid conditions; OR decrease ability to perform daily activities; OR cause adverse reaction or harm [chart notes required] OR
• BOTH Epclusa and Mavyret are not in the best interest of the patient based on medical necessity [chart notes required] OR
• There is support for the use of the requested agent over BOTH Epclusa and Mavyret (e.g., the patient is currently taking the requested agent) AND
• ONE of the following: The patient is treatment naïve OR previously treated with ONLY peg-interferon and ribavirin OR is an adult with hepatocellular carcinoma secondary to chronic hepatitis C genotype 1–4 OR is an adult with hepatitis C genotype 1–4 meeting criteria for simplified AASLD treatment and guidelines.
• If the client has preferred agent(s) for the patient's specific factors, one of the following must apply: request belongs to certain plan categories OR the patient has been treated with the requested agent in the past 30 days OR is currently stable on it [chart notes required] OR has tried and had inadequate response/adverse event/lack of efficacy/intolerance/contraindication to ALL preferred agents OR all preferred agents expected to be ineffective/harmful OR not in best interest medically [chart notes required] OR has tried another drug in same class and discontinued due to lack of efficacy/adverse event OR support exists for requested non-preferred agent.
• The prescriber has screened the patient for HBV infection AND if positive, will monitor for HBV reactivation during and after treatment.
• Prescriber is or consulted with gastroenterologist, hepatologist, or infectious disease specialist, OR patient meets AASLD simplified treatment criteria (adult, chronic HCV any genotype, treatment-naïve, without or with compensated cirrhosis (Child-Pugh A) per laboratory/imaging criteria).
• The patient does NOT have any FDA labeled contraindications to the requested agent AND will use requested drug in an FDA-approved regimen and route per Table 6 or 7 and requested duration does NOT exceed labeled duration.

Approval duration

6 months for BCBSIL/BCBSMT; ≥12 weeks up to treatment duration for BCBSNM