Revised Hepatitis C Drug Prior Authorization Form 1342

Published on
March 8, 2021

On March 1, 2021, Medicaid expanded coverage to include Metavir fibrosis score F2 for Hepatitis C treatment. HHSC recently revised the Antiviral Agents for Hepatitis C Virus Initial Request – Standard Prior Authorization Addendum (HHS Form 1342). Prescribing providers must use this form along with the Standard Prior Authorization Request (TDI Form NOFR002) for people enrolled in fee-for-service Medicaid.

Prescribers must use the MCO’s version of this form for people enrolled in managed care. Refer to the Prescriber MCO Assistance Chart (PDF) for contact information for each MCO. Refer to the MCO Resources for links to each MCOs website to find prior authorization information and forms.