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Changes to Hepatitis C Prior Authorization Criteria Begin September 1, 2021

Last updated on 9/1/2021

Beginning September 1, 2021, Medicaid will expand coverage of the hepatitis C virus clinical prior authorization criteria to include all metavir fibrosis scores. The Texas Health and Human Services Commission (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 DAA 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, 2021. The following revised hepatitis C prior authorization forms for Medicaid fee-for-service processing will be available on September 1, 2021:

  • 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 September 1, 2021.

Each Medicaid managed care organization (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 using the Prescriber Assistance Chart.

Contact vdp-formulary@hhsc.state.tx.us with comments or any questions.