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Sovaldi (sofosbuvir) — Blue Cross Blue Shield of Texas

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) The patient is a pediatric patient with a diagnosis of 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) The patient's age is within FDA labeling for the requested agent for the requested indication OR (2) There is support for using the requested agent for the patient's age for the requested indication OR (B) The patient is a pediatric patient with a diagnosis of hepatitis C genotype 2 or 3 AND ALL of the following: (1) 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 agent for the requested indication OR (B) There is support for using the requested agent for the patient's age for the requested indication AND (2) 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 patient is currently being treated with the non-preferred agent and the patient is currently stable on it [chart notes required]