Sovaldi (sofosbuvir) — Blue Cross Blue Shield of Oklahoma

Preferred products

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

Initial criteria

• 1. The patient has a diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6 AND
• 2. If the patient has an FDA labeled indication, then ONE of the following: A. The patient's age is within FDA labeling for the requested indication OR B. There is support for the use of the requested agent for the patient's age for the requested indication AND
• 3. The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection AND
• 4. If screening for HBV was positive for current or prior infection, the prescriber will monitor for HBV flare-up or reactivation during and after treatment AND
• 5. If the client has preferred agents for the patient's specific factors, then ONE of the following: A. The request is for a BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR B. The requested agent is preferred OR C. The patient has been treated with the non-preferred agent in the past 30 days OR D. The patient is currently stable on the non-preferred agent [chart notes required] OR E. The patient has tried and had an inadequate response to ALL preferred agents [chart notes required] OR F. Preferred agents discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR G. The patient has intolerance or hypersensitivity to ALL preferred agents [chart notes required] OR H. The patient has an FDA labeled contraindication to ALL preferred agents [chart notes required] OR I. ALL preferred agents expected to be ineffective or cause adherence barriers, worsen comorbidities, or cause harm [chart notes required] OR J. ALL preferred agents not in best interest based on medical necessity [chart notes required] OR K. Tried another drug in same class as ALL preferred agents and discontinued due to efficacy/adverse event [chart notes required] OR L. Prescriber provides clinical information supporting use of non-preferred agent over preferred agents AND
• 6. ONE of the following: A. Prescriber is a specialist (gastroenterologist, hepatologist, infectious disease) or has consulted with one OR B. ALL of the following: 1. Patient is treatment naïve AND 2. No or compensated cirrhosis AND 3. Requested agent is supported in AASLD guidelines for simplified treatment AND 4. Patient meets AASLD simplified treatment qualifications (eligible adults with chronic HCV with or without compensated cirrhosis as determined by FibroScan >12.5kPa, FIB-4>3.25, noninvasive markers, biopsy, imaging, platelet count <150,000/mm^3; not previously treated; no decompensated cirrhosis, pregnancy, hepatocellular carcinoma, or liver transplant) AND
• 7. The patient has not previously been treated with the requested agent AND
• 8. The patient does not have FDA labeled contraindications to the requested agent AND
• 9. The patient meets all requirements and will use the requested agent in a regimen per FDA labeling (Table 5) AND
• 10. The requested treatment duration does not exceed labeling.

Approval duration

6 months for BCBSIL/BCBSMT; up to regimen duration (≥12 weeks for BCBSNM)