Vosevi (sofosbuvir-velpatasvir-voxilaprevir) — CareFirst (Caremark)

Preferred products

• glecaprevir/pibrentasvir (Mavyret)
• sofosbuvir/velpatasvir (Epclusa)

Initial criteria

• Medication must be prescribed by or in consultation with a provider experienced in the management of hepatitis C virus infection
• Member must be an adult (age ≥ 18 years)
• Coverage will not be provided for members with decompensated cirrhosis or moderate/severe hepatic impairment (Child-Pugh class B or C)
• For HCV genotype 1, 2, 4, 5, or 6 infection without ribavirin: Authorization of up to 12 weeks total may be granted for members who failed prior treatment with any direct-acting antiviral regimen (e.g., NS5A- or sofosbuvir-containing regimen except glecaprevir/pibrentasvir [Mavyret])
• For HCV genotype 1, 2, 4, 5, or 6 infection without cirrhosis who failed prior treatment with glecaprevir/pibrentasvir (Mavyret): Authorization of up to 12 weeks total may be granted
• For HCV genotype 3 infection without cirrhosis: Authorization of up to 12 weeks total may be granted for members who failed prior treatment with any direct-acting antiviral regimen (e.g., NS5A- or sofosbuvir-containing regimen, including glecaprevir/pibrentasvir [Mavyret])
• For HCV genotype 3 infection with compensated cirrhosis: Authorization of up to 12 weeks total may be granted for treatment-naïve members who have the Y93H substitution associated with velpatasvir resistance
• For recurrent HCV infection post liver transplantation: Authorization of up to 12 weeks total may be granted for members with recurrent HCV genotype 1–6 infection who failed prior treatment with any direct-acting antiviral regimen (e.g., NS5A- or sofosbuvir-containing regimen)
• For kidney transplant recipients: Authorization of up to 12 weeks total may be granted for members with HCV genotype 1–6 infection who failed prior treatment with any direct-acting antiviral regimen (e.g., NS5A- or sofosbuvir-containing regimen)
• For HCV genotype 3 infection in combination with ribavirin: Authorization of up to 12 weeks total may be granted for members with compensated cirrhosis who failed prior treatment with any direct-acting antiviral regimen (e.g., NS5A- or sofosbuvir-containing regimen, including glecaprevir/pibrentasvir [Mavyret])
• For direct-acting antiviral treatment failure (genotype 1–6 infection): Authorization of up to 12 weeks total may be granted for members with compensated cirrhosis who failed prior treatment with glecaprevir/pibrentasvir (Mavyret)
• For direct-acting antiviral treatment failure (genotype 1–6 infection): Authorization of up to 24 weeks total may be granted for members with or without compensated cirrhosis who failed prior treatment with sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
• For recurrent HCV infection post liver transplantation after prior DAA failure: Authorization of up to 12 weeks total may be granted
• For kidney transplant recipients after prior DAA failure: Authorization of up to 12 weeks total may be granted
• For members with HCV and HIV coinfection: Authorization may be granted when the criteria for approval of the requested regimen in the coverage criteria above are met

Reauthorization criteria

• All members (including new members) requesting authorization for continuation of therapy must meet all requirements in the coverage criteria

Approval duration

up to 12 weeks total; up to 24 weeks total for certain direct-acting antiviral treatment failure cases