Revised Hepatitis C Drug Prior Authorization Forms Now Available

Published on
February 11, 2021

HHSC requires MCOs to follow the Hepatitis C virus clinical prior authorization criteria for people enrolled in Medicaid who require treatment with Direct-Acting Antiviral Agents (DAAs). Effective March 1, 2021, Texas Medicaid will expand coverage to include Metavir fibrosis score F2 and require an escalation process for other Medicaid clients with severe extrahepatic effects of chronic Hepatitis C with a Metavir fibrosis score other than F2, F3, or F4.  If a client does not meet the prior authorization criteria, but the prescribing provider determines treatment is required based on documentation of severe extrahepatic effects, then the escalation process would be necessary.

Pharmacies should continue using current criteria and current Hepatitis C prior authorization forms until February 28. Beginning March 1, pharmacies must use the following revised Hepatitis C prior authorization forms for clients in fee-for-service Medicaid:

  • Antiviral Agents for Hepatitis C Virus Initial Request – Standard Prior Authorization Addendum (HHS Form 1342).
    • Providers must use this form along with the Standard Prior Authorization Request (TDI Form NOFR002).
  • Antiviral Agents for Hepatitis C Virus Initial Authorization Request (HHS Form 1335)
    • This is a stand-alone Medicaid prior authorization form not requiring the use of the TDI form.
  • Antiviral Agents for Hepatitis C Virus Refill Authorization Request (HHS Form 1336)
    • No revisions were made to this document.

Due to the various age expansions for the Hepatitis C DAAs, the revised forms now include a more general statement indicating the prescribed treatment agent should be appropriate for the client's age. Clients enrolled with a Medicaid managed care organization (MCO) must use the MCO’s form.

Refer to the Prescriber MCO Assistance Chart for contact information for each MCO. Refer to the MCO Resources for links to each MCOs website to find prior authorization information and forms.