CurrentCareSourcePolicy AR-PAS-P-2606600a

Hepatitis C Virus (HCV) Medication Therapy Prior Authorization

Form and criteria governing prior authorization requests for Arkansas Medicaid members receiving HCV direct-acting antiviral (DAA) therapy; applies to prescribers submitting PA to CareSource Pharmacy PASSE for Arkansas members.

Policy Summary

PayerCareSource

PolicyHepatitis C Virus (HCV) Medication Therapy Prior Authorization

Policy CodePolicy AR-PAS-P-2606600a

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax a completed prior authorization form and required supporting documentation, including genotype and GT-1a resistance results, to CareSource PASSE Pharmacy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ArkansasApplicable Medicaid program/state

1-866-930-0019Fax number to submit completed PA

1-833-230-2100Provider Services phone

March 2024Revision Date

Authorization Coverage Criteria

Authorization coverage criteria

Covered when ALL of the following documented conditions and supporting materials are provided with the prior authorization request:

General submission and prescriber requirements: Completed prior authorization request form submitted to CareSource PASSE (fax as indicated); prescriber must be a hepatologist, gastroenterologist, infectious disease specialist, or a prescriber working under the direct supervision of one of these specialties.

See submission and prescriber rules in chunk 8.

Diagnosis documentation: Member has a documented diagnosis of acute or chronic Hepatitis C with the appropriate ICD-10 code (or other specified diagnosis with ICD-10 code entered).

Form requires diagnosis field; see chunk 7.

Genotype and regimen selection: HCV genotype is specified and the selected antiviral regimen and duration correspond to the genotype and treatment history options listed on the form (examples include Zepatier, Epclusa, Mavyret with indicated durations and addition of ribavirin when specified).

Policy Summary

PayerCareSource

PolicyHepatitis C Virus (HCV) Medication Therapy Prior Authorization

Policy CodePolicy AR-PAS-P-2606600a

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax a completed prior authorization form and required supporting documentation, including genotype and GT-1a resistance results, to CareSource PASSE Pharmacy.

SourceLink

On This Page

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Regimen options by genotype and treatment history are enumerated on the form; see chunk 4.

Treatment history: Treatment-naive or treatment-experienced status is documented; if treatment-experienced, list all previous drug regimen(s).

Form requests TN vs TE and prior regimens; see chunk 7.

Resistance testing for GT-1a: If genotype 1a, submit NSSA resistance-associated polymorphism testing results; this is mandatory for all GT-1a requests.

Chunk 6 states mandatory testing for GT-1a.

Liver disease severity and labs: Provide Child-Pugh score (CPS-A, B, or C) with supporting labs and chart notes for CPS-B or CPS-C as applicable; provide MELD score when applicable; include current liver function labs (platelets, INR, ALT, AST, etc.).

Form requests CPS and MELD and requires lab documentation; see chunks 6 and 7.

Comorbidities and special considerations: Document presence or absence of HIV/HBV co-infection, extrahepatic HCV manifestations, pregnancy, psychiatric history, anemia, autoimmune disease, kidney disease/transplant, unstable cardiovascular disease, untreated hyperthyroidism, thrombocytopenia, or other listed conditions; include relevant details when present.

Form lists comorbidities and special history items to be reported; see chunk 8.

Adherence and continuation criteria: Adherence with prescribed therapy is a condition for payment of continuation therapy; member's drug history will be reviewed prior to approval of continuation requests.

Chunk 6 notes adherence and drug history review as conditions for continuation.

Supporting documentation attached: Attach required supporting documentation with the PA request including required labs, resistance testing results (when required), and chart notes to substantiate disease stage and comorbidities; submission of lab results does not by itself guarantee approval of lab testing payment.

Chunk 6 and planner notes on required documentation.

Absence of required documentation can result in delayed review or denial of the prior authorization. Specifically, the PA must include supporting documentation such as current liver function labs (e.g., platelets, INR, ALT, AST) and any mandated resistance testing. Missing these items — or submitting incomplete, incorrect, or illegible information — risks postponement or non‑approval of the request.

Continuation of therapy is conditional on documented adherence with prescribed therapy; adherence is a stated condition for payment of continuation therapy for the allowed time frame for each HCV genotype. Prior to approving continuation, the member’s drug history will be reviewed. Submission of required supporting documentation is still necessary and does not by itself guarantee approval or payment for any associated lab tests.

Submission, Prescriber, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required. Fax the completed Arkansas Medicaid HCV Medication Therapy Request Sheet and all supporting documentation to the CareSource PASSETM Pharmacy prior authorization fax at 1-866-930-0019. Use one form per member. Incomplete, illegible, or missing information may delay or prevent approval.

Fax PA requests and documentation to CareSource PASSETM Pharmacy: 1-866-930-0019
Use one request form per member
PA requests may be submitted as Standard or Urgent on the form

Documentation Required

Submission and Prescriber Requirements

PA requests must be submitted by an authorized prescriber (typically the treating physician or other licensed provider authorized to prescribe HCV direct-acting antivirals). Include the completed request form plus the required clinical documentation and laboratory results described below. Adherence with prescribed therapy will be reviewed and is a condition for payment of continuation therapy.

Request must be submitted by the prescriber (treating physician or authorized prescribing clinician)
Include member identifiers and diagnosis (ICD-10 code for acute or chronic HCV or other with explanation)
If treatment-experienced, list all prior HCV regimens
Specify whether the request is new or a continuation

Documentation Required

Required Supporting Documentation and Labs

Include the following supporting documentation and laboratory results with every PA request. Failure to provide required labs (including genotype-specific tests) may result in delay or denial. Submitting labs does not guarantee payment for those lab tests.

HCV genotype (GT) with subtype (1a, 1b, 2, 3, 5, 6 as applicable)
For GT-1a: submit NSSA (Nucleotide/Non-structural Sequence Analysis) resistance-associated polymorphism testing results (mandatory for all GT-1a requests)
If applicable, documentation of prior treatment regimens (drug names, durations, response)
Liver disease staging: Child-Pugh score (CPS-A, B, or C) — provide labs and chart notes to support CPS-B and CPS-C
Model for End-Stage Liver Disease (MELD) score, if available
Baseline and current liver function tests and hematology: platelets, INR, ALT, AST, bilirubin, albumin as applicable
HIV/HBV co-infection status and relevant treatment information if co-infected
Documentation of extrahepatic HCV manifestations if claimed

Note

Regimen-Specific Selection Guidance

Regimen selection must align with genotype, prior treatment history, cirrhosis status, and resistance testing. Use the regimen and duration consistent with the member's GT and clinical status; when indicated, ribavirin (RBV) is added. Examples from the request form include regimen-duration pairings and conditional RBV use:

Zepatier (elbasvir/grazoprevir): commonly 12 weeks; add RBV and extend to 12–16 weeks for certain GT-1a or GT-4 treatment-experienced or RAV-resistant cases per clinical guidance
Epclusa (velpatasvir/sofosbuvir) or generic: 12 weeks for most genotypes and treatment statuses; add RBV for CPS-B/C or other specified conditions per form
Mavyret (glecaprevir/pibrentasvir): 8 weeks for treatment-naive without cirrhosis; 12 or 16 weeks for certain treatment-experienced or specific genotypes (see form) per clinical history
Ribavirin 200 mg formulations may be required as noted for selected regimens and genotypes
Select regimen/duration based on: genotype/subtype, treatment-naive vs experienced, cirrhosis status (no cirrhosis vs CPS-A/B/C), prior protease inhibitor exposure, and resistance testing results

Denial Risk

Incomplete Documentation May Delay or Prevent Approval

Notes and denial risk: incomplete documentation (missing genotype, resistance testing for GT-1a, incomplete liver labs, or missing prior-treatment history) may delay or prevent approval. Provide clear, legible, and current documentation with each request.

Mandatory: NSSA resistance results for all GT-1a requests
Provide current labs (platelets, INR, ALT, AST, bilirubin, albumin) and scores (CPS, MELD) when applicable
Supporting documentation does not guarantee approval or payment

Clinical Background

Chronic hepatitis C treatment requires genotype‑directed selection of direct‑acting antivirals, assessment of prior treatment experience, and evaluation of liver disease severity. The policy requires documentation of HCV genotype and, when applicable, mandatory resistance testing — notably for GT‑1a, where NSSA resistance‑associated polymorphism results are mandatory for all GT‑1a requests. Providers must also submit current liver function labs and other tests used to stage disease (for example, Platelets, INR, ALT, AST) to support regimen selection and severity assessments such as Child‑Pugh or MELD as indicated.

Abbreviations and Definitions

Key abbreviations

GTGenotype

TNTreatment Naive

TETreatment Experienced

CPSChild-Pugh Score (can be A, B or C)

RAVNSSA resistance-associated polymorphisms (negative [-] or positive [+] for resistance variants)