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.
  • Patient must have FDA recognized contraindication to use of Zepatier® (for Genotype 1 or 4)
  • 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: December 26, 2016

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.

Press Esc to cancel

El sitio Web al que está siendo transferido no es provisto por WHA. Las Condiciones de Uso y las Prácticas de Privacidad en Internet de WHA no se aplican a este sitio Web asociado que usted está usando. Revise las políticas sobre la privacidad y condiciones de uso de este sitio Web asociado. WHA no tiene control sobre la exactitud, la totalidad o la actualidad del contenido del sitio Web asociado. WHA no puede garantizar que los servicios de traducción de idiomas estarán disponibles en el sitio vinculado.

Presione «Esc» para cancelar