Changes to Hepatitis C Prior Authorization Criteria Begin Sept. 1

Published on
August 24, 2021

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:

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.