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SOFOSBUVIR-VELPATASVIR 400-100

Drug Details

General

Brand Name: SOFOSBUVIR-VELPATASVIR 400-100
Generic Name: sofosbuvir/velpatasvir
Manufacturer: ASEGUA THERAPEU
NDC: 72626270101
Package size: 28EA
Family Planning drug: No
Diabetic Supply Drug: No
HTW drug: No
HTWPlus drug: No
Long-acting reversible contraception product: No
Refill-to-soon Utilization*: 75%

Drug Pricing

Retail Pharmacy Cost: 282.85715
Retail Pharmacy Eff Date: 11/24/2020
Specialty Pharmacy Cost: 277.90714
Specialty Pharmacy Eff Date: 11/24/2020
Long-term Care Pharmacy Cost: 276.06857
Long-term Care Pharmacy Eff Date: 11/24/2020
340B Cost: 122.85714
Premium Preferred Generic Incentive†: Yes

* Impacts only claims paid by the Vendor Drug Program: traditional Medicaid, CSHCN, HTW, and KHC Programs.

† Refer to the Pricing and Reimbursement chapter of the Pharmacy Provider Procedure Manual for information about traditional Medicaid claim pricing and PPG pricing incentives.

‡ Refer to the Clinical Prior Authorization Assistance Chart (PDF) for the list of clinical prior authorization each MCO uses and how those authorizations relate to those used in traditional Medicaid. Refer to the MCO Resources page for links to each MCO’s clinical prior authorizations.

Program Coverage

Medicaid

Effective date: 09/25/2019
PDL PA Required: Yes
PDL Class: HEPATITIS C AGENTS
FFS Clinical PA Required‡: Yes
Compound-only use: No

CHIP

Compound-only use: No
Compound-only use: No

‡ Please review the lists of DUR board-approved clinical prior authorizations that apply to traditional Medicaid and those that health plans may use. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each health plan uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. Refer to the MCO Resources for links to each health plan's active clinical prior authorizations.