Sofosbuvir, Velpatasvir (Epclusa®)

ORAL ADMINISTRATION

Indications for Prior Authorization:

  • Treatment of chronic hepatitis C, Genotype 1, 2, 3, 4, 5, or 6 infection in patients without cirrhosis or with compensated cirrhosis or in combination with ribavirn in patients with decompensated cirrhosis.  

All of the following must be met as a condition for coverage:

  • Patient must have compensated liver disease by fibroscan ultrasound or biopsy, documenting stage 2, 3 or stage 4.  Acitest-Fibrotest is not accepted as documentation.
  • Resistance testing must be included with the prior authorization request for genotypes 1 and 3.
    • Treatment failure associated with HCV resistance to newly developed direct-acting antiviral agents is not an uncommon occurrence and poses a substantial problem to clinicians trying to re-treat patients who have failed available interferon-free treatments.

This Medication is Not Approvable for the following condition(s):

  • Patients with Stage 0 or Stage 1 fibrosis
  • Any condition not listed above as an approved indication

Dosing:

  • One tablet once daily for 12 weeks, with or without Ribavirin.  

Last review date: August 20, 2018