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Sovaldi (sofosbuvir) — Blue Cross Blue Shield of Texas

hepatitis C genotype 2

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 for the requested agent 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 the screening for HBV was positive for current or prior HBV infection, the prescriber will monitor the patient for HBV flare-up or reactivation during and after treatment with the requested agent AND
  • 5. If the client has preferred agent(s) for the patient's specific factors (e.g., age, genotype, cirrhosis status, treatment naive vs treatment experienced, previous treatment), 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 a preferred agent for the patient's specific factors OR (C) The patient has been treated with the requested non-preferred agent in the past 30 days OR (D) The patient is currently being treated with the requested non-preferred agent and is stable on it [chart notes required] OR (E) The patient has tried and had an inadequate response to ALL of the preferred agents [chart notes required] OR (F) ALL preferred agents were discontinued due to lack of efficacy or 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 are expected to be ineffective, cause barrier to adherence or worsen a comorbid condition [chart notes required] OR (J) ALL preferred agents are not in the best interest of the patient based on medical necessity [chart notes required] OR (K) The patient has tried another prescription drug in the same pharmacologic class or mechanism of action and it was discontinued due to lack of efficacy or adverse event [chart notes required] OR (L) The prescriber has provided clinical information supporting use of the requested non-preferred agent over the preferred agents AND
  • 6. ONE of the following: (A) The prescriber is a specialist in the area of the patient's diagnosis (e.g., gastroenterologist, hepatologist, or infectious disease) or has consulted with such specialist OR (B) ALL of the following: (1) The patient is treatment naive AND (2) The patient does not have cirrhosis or has compensated cirrhosis AND (3) The requested agent is supported in AASLD guidelines for simplified treatment AND (4) The patient meets all of the qualifications for AASLD simplified HCV treatment.
  • 7. The patient has not been previously treated with the requested agent AND
  • 8. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • 9. The patient meets all requirements and will use the requested agent in a treatment regimen noted in Table 5 (FDA labeling) AND
  • 10. The requested length of therapy does NOT exceed the FDA labeled duration for the patient's treatment regimen.

Approval duration

6 months (BCBSIL, BCBSMT); up to duration of treatment per Table 5 (≥12 weeks for BCBSNM)