Anthem Blue Cross (HMO, PPO, EPO)
sofosbuvir-velpatasvir (sofosbuvir-velpatasvir)
Drugs for Infections : Drugs for Viral Infections
  • Prior Authorization: Antiviral: Hepatitis C (HCV):
    Documented Diagnosis: Yes
    Age Requirement: >= 3

  • Antiviral: Hepatitis C (HCV):
    Age Requirement: >= 3
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Documented Genotype(s): 1 of Genotype 1;Genotype 2;Genotype 3;Genotype 4;Genotype 5;Genotype 6
    History of Substance Abuse: No
    If History of Substance Abuse, Drug Abstinence Duration: N/A
    If History of Substance Abuse, Appropriate Clean Drug Screen: No
    Policy Contains a Once in a Lifetime Restriction: No
    Co-Infection with Hepatitis B Prohibited in the Policy: No
    Extra-hepatic Disease Prohibited in Policy: No
    Treatment Duration Extended for Hepatocellular Carcinoma: No
    Concomitant Therapy with RBV: Yes
    Concomitant Therapy with RBV + IFN: No
    Concomitant Therapy with Daklinza: No
    Concomitant Therapy with Sovaldi: No
    Patient Must Not Have Been Previously Treated With a NS3-4A: No
    Patient Must Not Have Been Previously Treated With a NS-5A: Yes
    Fibrosis Score Required for Authorization: Yes
    Hepatic Fibrosis Score Required in Policy: FV0+

  • Step Therapy: Antiviral: Hepatitis C (HCV):
    ST Single Brand

  • Available only through Specialty Pharmacy;
    For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click HERE;
  • PA Applies
  • Quantity Limit: 1 tablet per 1 day(s).