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Epclusa® (sofosbuvir/velpatasvir) (New)
Act
by Dec 15, 2026
Effective date
Jan 1, 2027
Identified
Sep 30, 2026
Summary
Humana has implemented a new prior authorization policy for Epclusa® (sofosbuvir/velpatasvir) effective January 1, 2027, for Medicare Advantage members with chronic hepatitis C. The policy requires prior auth for both brand and generic formulations, with approval duration of 12 weeks or based on AASLD treatment guidelines. Brand Epclusa requires documentation that the member cannot use generic sofosbuvir/velpatasvir.
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What to do
by Dec 15, 2026 · 5 steps
01Billing and prior authorization teams must implement this new prior authorization requirement in all billing and authorization systems for Epclusa® (sofosbuvir/velpatasvir) and generic sofosbuvir/velpatasvir.
02For brand Epclusa requests, update authorization protocols to verify that the member cannot use generic sofosbuvir/velpatasvir before approval.
03Providers must obtain prior authorization before dispensing; claims submitted without prior auth will be denied.
04Update encounter forms and pharmacy submission templates to include HCV diagnosis confirmation and, for brand requests, documentation of generic contraindication or medical necessity.
05Training required for billing staff, prior auth reviewers, and providers on the two new approval criteria.
Original notice
Epclusa® (sofosbuvir/velpatasvir) (New)
mcp.humana.com · Always check the source before changing claims.