sofosbuvir/velpatasvir tablets (authorized generic to Epclusa – Gilead) — Cigna
Chronic Hepatitis C Virus (HCV), Genotype 1, 2, 3, 4, 5, or 6, Decompensated Cirrhosis (Child-Pugh B or C), Prior Null Responder, Prior Partial Responder, and Prior Relapser to sofosbuvir/velpatasvir or Vosevi
Initial criteria
- Patient is age ≥ 3 years; AND
- Patient has decompensated cirrhosis (Child-Pugh B or C); AND
- Patient meets ONE of the following (i or ii): i. Patient has been previously treated with sofosbuvir/velpatasvir; OR ii. Patient has previously been treated with Vosevi; AND
- Medication will be prescribed in combination with ribavirin; AND
- Medication is prescribed by or in consultation with a gastroenterologist, hepatologist, infectious diseases physician, or a liver transplant physician
Approval duration
24 weeks