Provider Alert! Changes to Hepatitis C Drug Coverage and Prior Authorization

Date: February 16, 2021

Attention: Gastroenterologists and Hepatologists

Effective Date: March 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: HHSC requires managed care organizations (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).

Due to the various age expansions for the Hepatitis C DAAs, there will be several changes to the prior authorization (PA) process. This includes modified criteria, revised forms, and an escalation process. Additional details, including links to the prior authorization forms, are found below.

How this impacts providers: The Vendor Drug Program (VDP) will modify the Hepatitis C prior authorization criteria in multiple phases:

• Effective March 1, 2021, coverage will expand to include Metavir fibrosis score F2.
• Effective September 1, 2021, coverage will include all Metavir fibrosis scores. Additionally, HHSC will remove the specialist and drug screening requirements.
• Effective March 1, 2021, providers will need to use revised initial request prior authorization forms. The forms will include a more general statement indicating the prescribed treatment should be appropriate for the Medicaid MCO client’s age. A link to the updated form is included below.
• There will be an escalation process for members with severe extrahepatic effects of chronic Hepatitis C with a Metavir fibrosis score other than F2, F3, or F4. If a member does not meet the prior authorization criteria, but the prescribing provider determines treatment is required based on documentation of severe extrahepatic effects, then provider will be able to escalate an exceptions request. More details of the process are forthcoming.

Next steps for providers: Providers should share this communication with their staff. Providers should continue using current criteria and current Hepatitis C prior authorization forms until February 28, 2021.  The revised Hepatitis C virus clinical prior authorization forms are forthcoming. Providers can obtain the new forms from the Navitus website once it is available.

Resource:

1. Navitus TX Medicaid Prior Authorization forms

If you have any questions, please email TCHP Pharmacy Department  at: tchppharmacy@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.