Epclusa® and sofosbuvir/velpatasvir

Authorization forms

Traditional (10/2020)

Optimized (10/2020)

Note: Brand Epclusa is not covered for Traditional or Optimized members

Priority Health Medicare Part D no longer utilize drug-specific prior authorization forms for drugs covered under the pharmacy benefit.

Visit the Approved Drug List (ADL) to search by drug name and view the criteria and PA form.

Go to Medicare ADL