CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vosevi (sofosbuvir/velpatasvir/voxilaprevir) for chronic Hepatitis C

Defines coverage and prior-authorization criteria for Vosevi for adult members with chronic HCV infection (various genotypes), including genotype-specific retreatment and post-transplant indications, exclusions for decompensated cirrhosis, prescriber specialty requirements, and continuation rules.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVosevi (sofosbuvir/velpatasvir/voxilaprevir) for chronic Hepatitis C

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionRequest prior authorization and document genotype, prior antiviral regimens (including NS5A or sofosbuvir), cirrhosis and transplant status, and any resistance substitutions (e.g., Y93H).

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy criteria.

6Genotypes referenced (1-6)

12wTypical maximum authorization

24wMax after prior Vosevi failure

Coverage Summary & Indications

Covered Indications / Initial Authorization

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Continuation Therapy

Continuation of Therapy

All members requesting continuation must meet initial authorization criteria.

Continuation requirement: Member meets all initial authorization criteria

All members (including new members) requesting authorization for continuation of therapy must meet all initial authorization criteria.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must include the indication for treatment and a documented prior-treatment history. Submit supporting documentation including HCV genotype, prior regimens (specifically whether prior therapy included an NS5A inhibitor and/or sofosbuvir), cirrhosis status (including Child‑Pugh class), transplant status (e.g., history of liver or kidney transplant), and any known resistance-associated substitutions (e.g., Y93H).

Required: HCV genotype
Required: Prior antiviral regimens and outcomes (note NS5A-containing regimens and sofosbuvir exposure)
Required: Cirrhosis status with Child‑Pugh classification
Required: Transplant status (liver or kidney)
Recommended: Documented resistance-associated substitutions (e.g., Y93H)

Documentation Required

Prescriber Specialty Documentation

The prescriber must be a specialist in infectious disease, gastroenterology, hepatology, or transplant, or the prescription must be written in consultation with one of these specialists. Documentation of the specialist prescriber or consultation should be provided with the request.

Prescriber specialty: infectious disease, gastroenterology, hepatology, or transplant
If not the specialist, include documentation of specialist consultation

Denial Risk

Exclusion for Decompensated Cirrhosis

Claims will be denied for members with decompensated cirrhosis (Child‑Pugh Class B or C). Ensure Child‑Pugh classification is documented; requests for members with moderate or severe hepatic impairment will not be approved.

Denial applies to Child‑Pugh B or C (decompensated cirrhosis / moderate-severe hepatic impairment)

Documentation Required

Supporting Information That May Be Requested

The plan may request additional supporting information to complete review of the authorization request. Provide these items when available to avoid delays.

Treatment status: treatment‑naïve or retreatment
For initial treatment: confirmation of member readiness
For retreatment: reason for retreatment (e.g., prior treatment failure, reinfection), confirmation of readiness, and adherence plan
Hepatitis B screening results
Metavir or fibrosis score

Background

Vosevi (sofosbuvir/velpatasvir/voxilaprevir) is indicated for the treatment of adult patients with chronic hepatitis C virus (HCV) infection without cirrhosis or with compensated cirrhosis (Child-Pugh A) for specific genotype and prior-treatment scenarios as described in FDA labeling and AASLD/IDSA guidance.

Prescriptions should be from or in consultation with a prescriber specializing in infectious disease, gastroenterology, hepatology, or transplant per policy and labeling.

Compensated cirrhosis: Child-Pugh A cirrhosis (policy treats compensated cirrhosis as eligible).

Decompensated cirrhosis: Child Turcotte Pugh Class B or C — excluded from coverage; moderate or severe hepatic impairment is not eligible.

NS5A inhibitor: Class of direct-acting antiviral agents referenced as a prior-regimen component (policy references prior treatment with an NS5A inhibitor as an eligibility determinant).

Surface Thresholds

Maximum authorized duration for most indicationsup to 12 weeks

Maximum authorized duration after prior Vosevi failureup to 24 weeks

Scope summaryDefines coverage and prior-authorization criteria for Vosevi for adult members with chronic HCV infection (genotypes 1–6) including genotype-specific retreatment and post-transplant indications; requires specialist prescriber, documents prior antiviral regimens and cirrhosis status; excludes decompensated cirrhosis; continuation requires meeting initial criteria.