Sofosbuvir, Velpatasvir (Epclusa®)
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
- One tablet once daily for 12 weeks, with or without Ribavirin.
Last review date: December 26, 2016