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Sovaldi (sofosbuvir) — Blue Cross Blue Shield of Oklahoma

Pediatric hepatitis C genotype 2 or 3

Preferred products

  • Epclusa (sofosbuvir/velpatasvir)
  • Sofosbuvir/Velpatasvir
  • Mavyret (glecaprevir/pibrentasvir)

Initial criteria

  • 1. ONE of the following: A. Pediatric patient with hepatocellular carcinoma secondary to chronic hepatitis C genotype 2 or 3 AND if the patient has an FDA labeled indication, ONE of the following: 1. Age within FDA labeling OR 2. Support for use in age OR
  • B. Pediatric patient with hepatitis C genotype 2 or 3 AND ALL of the following: 1. If FDA labeled indication, ONE of the following: A. Age within FDA labeling OR B. Support for use in age AND 2. ONE of the following: A. Request is for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR B. Patient currently being treated and stable on non-preferred agent [chart notes required]