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

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 an 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 or cause a significant barrier to adherence, worsen a comorbid condition, decrease functional ability, or cause an adverse reaction or 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 (e.g., patient is currently taking the requested agent) AND
• ONE of the following: The patient is treatment naive OR previously treated only with peg-interferon and ribavirin OR is an adult with a diagnosis of hepatocellular carcinoma secondary to chronic HCV genotype 1-4 OR is an adult with chronic HCV genotype 1-4 meeting step therapy logic below
• If the client has preferred agent(s) for the patient's specific factors, ONE of the following must apply: request is for eligible plan type OR patient treated with or stable on requested agent OR inadequate response, discontinuation for lack of efficacy or adverse events, intolerance, FDA labeled contraindication, expected ineffectiveness or harm, best interest based on medical necessity, or tried another agent in same class and discontinued due to lack of efficacy/adverse event OR support for use over preferred agent(s) [chart notes required]
• Prescriber has screened patient for current or prior HBV infection AND will monitor for HBV flare or reactivation if positive
• EITHER prescriber is a gastroenterologist, hepatologist, or infectious disease specialist OR has consulted such OR patient meets AASLD simplified treatment criteria (treatment naive, compensated cirrhosis or none, meets all simplified protocol qualifications)
• Patient has no FDA labeled contraindications to requested agent AND requested regimen and duration consistent with FDA labeling tables (Tables 6 or 7)

Approval duration

6 months (BCBSIL and BCBSMT); otherwise up to duration of treatment per FDA table (≥12 weeks for BCBSNM)