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Revised Hepatitis C Drug Prior Authorization Forms Now Available

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Effective March 1, 2021, Texas Medicaid will expand coverage to include Metavir fibrosis score F2 and require an escalation process for Medicaid clients with severe extrahepatic effects of chronic Hepatitis C with a Metavir fibrosis score other than F2, F3, or F4.

Because of this expansion, the prior authorization requirements and forms have been updated. If a Medicaid or Medicaid managed care 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.

Medicaid Fee-for-Service

Prescribing providers should continue using current criteria and current Hepatitis C prior authorization forms until February 28, 2021. Beginning March 1, 2021, providers must use the following revised Hepatitis C prior authorization forms for patients in fee-for-service Medicaid:

Important: 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)

Important: This is a stand-alone Medicaid prior authorization form not requiring the use of the TDI form. The HHS Form 1336 is not being revised:

Providers may continue to use the Antiviral Agents for Hepatitis C Virus Refill Authorization Request (HHS Form 1336), because there were no revisions made to this form.

Note: Clients enrolled in a Medicaid managed care organization (MCO) should refer to the MCO and the following:

Managed Care Organizations

The Texas Health and Human Services Commission (HHSC) requires MCOs to follow the same Hepatitis C virus clinical prior authorization criteria guidelines as Texas Medicaid for treating clients who require treatment with Direct-Acting Antiviral Agents (DAAs). Based on documentation of severe extrahepatic effects, then the escalation process would be necessary.

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 Medicaid MCO client's age. Providers must use the prior authorization forms of the Medicaid MCO in which the client is enrolled.

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.

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