Treatment of Hepatitis C — Prior Authorization Guidelines
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Rhode Island Medicaid prior authorization guidelines for pharmacologic treatment of Hepatitis C, detailing eligibility, required documentation, preferred and non-preferred agents, and continuity of treatment rules for beneficiaries and enrolled prescribers.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial coverage criteria
Covered when ALL of the following are met
Preferred agents as of August 1, 2021 are Mavyret and Vosevi; non-preferred agents are all others except ribavirin.
Continuity of Treatment
Continuity of care
The policy differentiates between preferred and non-preferred hepatitis C agents. Preferred agents as of August 1, 2021 are Mavyret® and Vosevi®. For medications that are not on the Preferred Drug List, Prior Authorization is required. Requests for non-preferred agents will be reviewed on a case-by-case basis and must include clinical documentation demonstrating the need for an alternative non-preferred agent; absent such documentation the request may not be approved. The policy also notes that non-preferred agents may be approved if the patient is completing a cycle of therapy that began prior to the policy effective date.
The document does not enumerate specific conditions or procedures labeled as not medically necessary. Instead, it sets coverage rules and process-based limits—most notably requiring Prior Authorization for non-preferred medications and demanding clinical justification for alternative agents. In practice, this means there is no standalone list of "not medically necessary" situations within this policy; coverage determinations rely on the stated eligibility criteria, required documentation, and the Preferred Drug List status of the requested medication.
Provider Requirements and Authorization Workflow
Prior authorization required for non‑preferred agents
Prior Authorization is required for any Hepatitis C medication that is not listed on the Preferred Drug List. Mavyret does not require prior authorization; Vosevi does not require prior authorization when used as a salvage medication after prior treatment failure.
- “Prior Authorization is required for medications not on the Preferred Drug List.”
- “Prior Authorization is not required when prescribing Mavyret®.”
- “Prior Authorization is not required for prescribing Vosevi® when used as a salvage medication after prior treatment failure.”
Use preferred agents first; non‑preferred require case‑by‑case review
Mavyret and Vosevi are designated as the preferred agents. All other hepatitis C agents are non‑preferred (except ribavirin) and will be reviewed on a case‑by‑case basis; approval of non‑preferred agents requires inclusion of clinical documentation demonstrating the need for an alternative agent.
- “Preferred agents: Mavyret® and Vosevi®.”
- “Non preferred agents: all other agents with exception of ribavirin; ... Will be reviewed on a case by case basis.”
- “The Prior Authorization request must include clinical documentation of need for an alternative, nonpreferred agent.”
Documentation to include with requests
Submit documentation that the prescriber is enrolled with Rhode Island Medicaid, the beneficiary’s Hepatitis C stage, prior Hepatitis C treatment history when relevant, and a treatment plan including medication name, dose and duration; agree to submit post‑treatment viral load data if requested.
- “Prescribers must be enrolled as a billing provider or an ordering, prescribing or referring (OPR) provider with Rhode Island Medicaid.”
- “All patients with documented Hepatitis C Stages 0 through 4 are eligible for treatment.”
- “History of prior Hepatitis C treatment if relevant.”
- “Treatment plan which includes: Medication name, dose and duration.”
- “Agreement to submit post treatment viral load data if requested.”
- “Treatment request for non-preferred medications require genotyping.”
Non‑preferred medication requests require PA and justification
Requests for non‑preferred medications require prior authorization and will be reviewed case‑by‑case; failure to provide clinical documentation of need for an alternative non‑preferred agent may lead to denial.
- “Treatment request for non-preferred medications require genotyping.”
- “Will be reviewed on a case by case basis. The Prior Authorization request must include clinical documentation of need for an alternative, nonpreferred agent.”
Key Definitions and Eligible Populations
Clinical Background
Hepatitis C is identified in the policy as a major cause of chronic liver disease with associated comorbidities, hepatocellular carcinoma, need for transplantation, and death. These clinical impacts frame the justification for broad treatment eligibility and the requirement that prescribers submit documentation (including disease stage and prior treatment history when relevant) to determine coverage for pharmacologic therapy under Rhode Island Medicaid.
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