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

Preferred products

• Epclusa (sofosbuvir/velpatasvir)
• Mavyret (glecaprevir/pibrentasvir)
• Zepatier (elbasvir/grazoprevir)

Initial criteria

• Diagnosis of hepatitis C genotype 1, 2, 3, 4, 5, or 6
• If genotype 1, prescriber must provide patient's subtype
• Patient is NOT treatment naive
• Patient has NOT been previously treated with the requested agent
• If the patient has an FDA-labeled indication, then ONE of the following: A) age is within FDA labeling for the indication and requested agent OR B) there is support for the use in this age for the indication
• Prescriber has screened the patient for current or prior hepatitis B viral (HBV) infection
• If HBV screen positive, prescriber will monitor for HBV flare-up or reactivation during/after treatment with requested agent
• If preferred agents exist for patient-specific factors, then ONE of the following applies: (A) specific plan type, (B) prior treatment with requested non-preferred within 30 days, (C) requested agent is preferred for patient’s factors, (E) stable on requested non-preferred, (F) inadequate response to all preferred, (G) discontinued all preferred due to inefficacy/adverse event, (H) intolerance/hypersensitivity to all preferred, (I) FDA contraindication to all preferred, (J) all preferred expected ineffective/contraindicated/detrimental, (K) not in best interest based on medical necessity, (L) tried other prescription drug same class as all preferred stopped due to AE/lack of efficacy, (M) supported use of non-preferred over preferred
• ONE of the following: (A) Prescriber is a specialist (gastroenterologist, hepatologist, infectious disease) OR (B) patient is treatment naive AND without or with compensated cirrhosis AND regimen supported in AASLD simplified treatment guidelines AND patient meets qualifications for simplified treatment
• Patient does NOT have any FDA labeled contraindications to requested agent
• Patient meets all treatment regimen requirements in Table 9
• Requested duration does NOT exceed duration in Table 9 (FDA labeling)

Approval duration

6 months (BCBSIL, BCBSMT); up to duration of treatment in Table 9 (others, at least 12 weeks for BCBSNM)