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

Initial criteria

• For general approval: The patient meets the above hepatitis C criteria and Table 9 treatment recommendations for previously treated genotype 1–6 patients per FDA labeling
• For Ohio residents (fully insured or HIM Shop [SG]): The patient resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH of the following: (A) The patient has no FDA labeled contraindications to the requested agent AND (B) ONE of: another FDA labeled indication for the requested agent, an indication supported in compendia for the requested route, or prescriber submitted two peer-reviewed journal articles showing safety and efficacy (randomized/double-blind/placebo-controlled; case studies not acceptable; specific compendia levels allowed)

Approval duration

12 months (Ohio); otherwise up to Table 9 treatment duration