Beginning September 1, 2021, Medicaid will expand coverage of the Hepatitis C virus clinical prior authorization criteria to include all metavir fibrosis scores. HHSC will modify the requirements as follows:
- Treatment with a direct-acting antiviral (DAA) medication on the formulary will be available to Medicaid clients regardless of metavir fibrosis scores.
- HHSC no longer restricts the prescribing of a DDA medication to a specialist provider. These medications can now be prescribed by general practitioners as well.
- A drug screening will no longer be required.
- No additional refill authorization is required to continue DAA treatment.
HHSC requires the clinical prior authorization criteria for all Medicaid clients, both fee-for-service and managed care. Providers should continue using the current criteria and forms until August 31. The following revised Hepatitis C prior authorization forms for Medicaid fee-for-service processing will be available on Sept. 1:
- Antiviral Agents for Hepatitis C Virus - Initial Request (HHS Form 1335)
- Antiviral Agents for Hepatitis C Virus - Initial Request - Addendum (HHS Form 1342)
HHSC will no longer require the Antiviral Agents for Hepatitis C Virus - Refill Request (HHS Form 1336) on Sept. 1.
Each MCO will have its own version of the Hepatitis C prior authorization forms with their specific contact information. Contact each MCO for prior authorization forms and submission instructions.