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

Chronic hepatitis C genotype 1, 2, 3, or 4

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 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 the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental 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 applies: The patient is treatment naive OR The patient was previously treated with ONLY peg-interferon and ribavirin OR The patient is an adult and has a diagnosis of hepatocellular carcinoma secondary to chronic hepatitis C genotype 1, 2, 3, or 4 OR The patient is an adult with genotype 1–4 meeting detailed conditions including treatment-naive or prior peg-interferon/ribavirin exposure and step-therapy exceptions satisfied for preferred agents
  • The prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection AND will monitor for reactivation if positive
  • The prescriber is a specialist in gastroenterology, hepatology, or infectious diseases, or has consulted with one OR meets all simplified treatment AASLD guideline qualifications (treatment-naïve adult, no or compensated cirrhosis, etc.)
  • The patient has no FDA labeled contraindication to the requested agent
  • The requested agent is used in a regimen and duration according to FDA labeling (Tables 6 or 7)

Approval duration

6 months or up to labeled duration (≥12 weeks for BCBSNM)