CurrentAlaska MedicaidPolicy N/A

Direct Acting Antivirals for Hepatitis C (HCV) — Coverage Criteria

Prior authorization and quantity limit policy for FDA‑approved direct acting antiviral (DAA) medications for treatment of chronic hepatitis C virus (HCV) infection for Alaska Medicaid members, including approval criteria, authorized regimens, and renewal requirements.

Policy Summary

PayerAlaska Medicaid

PolicyDirect Acting Antivirals for Hepatitis C (HCV) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of chronic HCV diagnosis, genotype, hepatic status (Child‑Pugh), prior therapy history, patient readiness attestation, and plan for SVR12 monitoring.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All genotypesHCV genotypes covered

≥18 (12–18 w/ specialist)Age eligibility

MavyretPreferred agent

SVR12 requiredPost-therapy follow-up

Child-Pugh B/CSpecialist requirement

Policy Summary

PayerAlaska Medicaid

PolicyDirect Acting Antivirals for Hepatitis C (HCV) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Authorization Criteria

Covered when ALL of the following are met for initial authorization:

Initial Authorization: 1. Diagnosis of chronic Hepatitis C infection; AND 2. Documentation of chronic hepatitis C infection status, HCV genotype, viral resistance-status (when applicable), hepatic status including Child-Pugh score, and HCV viral load is included in the authorization request; AND 3. Adult patient age ≥ 18 years (OR youth aged 12–18 when managed directly or in consultation by a specialist); AND 4. Documentation of prior HCV therapies, including dates, whether therapy was completed or discontinued, and if discontinued the reason, and any viral resistance-status; AND 5. Patient readiness assessment completed and patient attestation of compliance submitted and on file in the medical record; AND 6. Patient agrees to complete the regimen and has signed attestation acknowledging regimen completion, reinfection risk, and liver‑damage contributors; AND 7. Prescriber agrees to maintain HCV RNA levels obtained at 12 weeks post‑therapy to demonstrate Sustained Virologic Response (SVR) and retain records available upon request.none

All items must be documented in the PA request or medical record

Renewal and Extended Duration Criteria

Renewal/extended duration covered when ALL of the following are met:

Renewal Authorization: 1. For regimens with durations longer than 16 weeks, HCV RNA may be required to be submitted for treatment week 4 in sufficient time for renewal review; AND 2. HCV RNA must be < 25 IU/mL at treatment week 4; AND 3. Prescriber must maintain documentation of HCV RNA levels at treatment weeks 4 and 8 and at 12 weeks post‑therapy (SVR12), available upon request; AND 4. Extended durations will not be approved if there is no clinical evidence of benefit or if the need for extension was precipitated by patient non‑compliance; AND 5. Extended authorization or re‑authorization will not be granted for treatment failure resulting from a pharmacy dispensing error (pharmacy responsible); AND 6. Lost or stolen medication replacement requests will not be authorized.HCV RNA <25 IU/mL at week 4

Applies to renewal/extension requests

Resistance testing requirement: If the selected regimen or FDA labeling requires resistance‑associated polymorphism testing, the required testing must be completed and results submitted with the request; testing may also be required if deemed medically necessary by the clinical reviewer prior to approval.as specified by regimen/FDA

Testing required for certain regimens

Regimen Authorization and Specialist Restriction

Regimen selection rules and specialist restrictions:

Preferred regimens: Mavyret is the preferred agent for many genotypes and treatment‑experience scenarios (e.g., treatment‑naïve without cirrhosis: 8 weeks; compensated cirrhosis Child‑Pugh A: 12 weeks for many genotypes; selected genotype 3 scenarios: 16 weeks as noted in the regimen table).durations per policy table

Refer to the policy table for exact genotype and treatment‑experience mappings

When preferred agent cannot be used: If the preferred agent cannot be used due to a documented clinical contraindication, alternative agents (for example, Zepatier for certain GT1/4 indications or Epclusa for certain GT2/3 indications) are allowed but are restricted to specialist prescribing or require consultation with a specialist; documentation of the specific clinical contraindication must be submitted with the authorization request.documented clinical contraindication

Specialist restriction and FDA‑approved indication required

Requests for treatment of acute hepatitis C infection are excluded from coverage and will be denied. The policy’s denial criteria explicitly list a request for diagnosis of acute hepatitis C infection as a basis for denial.

Combination therapy including ribavirin is contraindicated in patients who are pregnant and in men whose partners are pregnant because of the risk of birth defects and fetal death. Documentation of pregnancy risk and appropriate counseling must be considered and provided when ribavirin exposure is possible; absence of such consideration is a trigger for denial.

Agents that are FDA-approved but for which clinical benefit has not been established will not be approved under this policy. In addition, use of a non-preferred agent without a documented clinical contraindication to preferred agents or without trial of an appropriate preferred option is not supported and may be denied.

What Providers Must Do / Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Direct Acting Antivirals (DAAs) for chronic hepatitis C. Approval requires meeting the policy clinical criteria and submission of required documentation. Prescribers must perform a patient readiness assessment and submit a signed patient attestation of treatment compliance.

Prior authorization required for all DAA requests
Prescriber must perform patient readiness assessment and submit signed attestation
Approval contingent on meeting documented clinical criteria

Step Therapy

Preferred Agent Requirement / Step Therapy

Alaska Medicaid requires use of preferred HCV agents (for example, Mavyret) when a medically appropriate preferred agent is available. A non-preferred agent will only be approved if there is a documented clinical reason (e.g., intolerance, contraindication, or prior treatment failure) supporting medical necessity for the non-preferred product.

Preferred agent requirement: trial or contraindication documentation required before non-preferred agent will be approved
Example preferred agent: Mavyret (when medically appropriate and available)

Documentation Required

Required Documentation with Prior Authorization

Authorization requests must include documentation of chronic HCV diagnosis and supporting clinical information. Incomplete requests will be non-clinically denied after 7 calendar days if requested information is not provided.

Required with PA: diagnosis of chronic HCV, HCV genotype, viral resistance status (when applicable), hepatic status (Child-Pugh score), and HCV viral load
Required with PA: documentation of prior HCV therapies, dates, completion status or reason for discontinuation, and resistance data if available
Required with PA: HBV screening (HBsAg and anti-HBc); if HCV/HIV co-infected, include CD4 count, HIV viral load, and HIV regimen
Required with PA: signed patient attestation of readiness/compliance and prescriber agreement to obtain SVR12 HCV RNA

Denial Risk

Triggers for Denial

Requests will be denied under specified conditions including clinical and documentation deficiencies. If incomplete information is submitted, prescribers have 7 calendar days to respond to avoid non-clinical denial.

Request for acute hepatitis C infection — DENY
Request for a non-preferred agent when a medically appropriate preferred agent is available — DENY
Request for a preferred agent for duration exceeding the FDA‑approved duration for the indication — DENY
Patient readiness not assessed or signed attestation not included — DENY
Active substance dependency without referral for treatment — DENY
Patient Child‑Pugh score > 6 (Class B or C) without management by or consultation with a liver disease specialist — DENY
Concomitant medications that counteract DAA efficacy or create safety risk — DENY
Patient age 12–18 years not managed by or in consultation with a liver disease specialist — DENY
Request for a non-preferred agent when a less expensive, medically appropriate preferred agent is available — DENY
Incomplete PA requests: prescriber has 7 calendar days to provide requested information or the PA will be non-clinically denied

OpenPayer

Direct Acting Antivirals for Hepatitis C (HCV) — Coverage Criteria

Coverage and Medical Necessity Criteria

What Providers Must Do / Authorization Requirements

Definitions and Key Terms

Background and Clinical Context