Treatment of Hepatitis C Prior Authorization Guidelines
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Rules governing prior authorization, preferred and non-preferred hepatitis C antiviral medications, and documentation requirements for Rhode Island Medicaid beneficiaries and enrolled prescribers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial therapy / Approval criteria
Covered when ALL of the following are met
From General Approval Criteria A in the policy.
From General Approval Criteria B.i in the policy.
From General Approval Criteria C.vi and C.vi.ii in the policy.
From General Approval Criteria C.i–C.ii in the policy.
From General Approval Criteria C.iii–C.iv in the policy.
From General Approval Criteria C.v in the policy.
Prior Authorization is not required when prescribing Mavyret®. Vosevi® also does not require prior authorization when used as a salvage medication after prior treatment failure in accordance with its FDA‑approved indication; refer to the package insert for details. For all other Hepatitis C antiviral medications that are not on the Preferred Drug List, Prior Authorization is required. This policy designates Mavyret® and Vosevi® as the preferred agents; non‑preferred medications will only be approved to complete a therapy course that began before the policy effective date or on a case‑by‑case basis with clinical justification and required documentation.
Prescriber Requirements & Prior Authorization
When prior authorization is required
Prior authorization is required for medications not on the Rhode Island Medicaid Preferred Drug List. Prior authorization is not required when prescribing Mavyret®. Prior authorization is also not required for Vosevi® when used as a salvage medication after prior treatment failure (see package insert for FDA‑approved indication).
Preferred vs non‑preferred agent rules
Mavyret® and Vosevi® are designated as preferred agents. Non‑preferred agents will be approved only to complete a cycle of therapy that began before the policy effective date or will be reviewed case‑by‑case; such requests must include clinical documentation of need for an alternative, nonpreferred agent.
- Preferred agents: Mavyret® and Vosevi®.
- Non‑preferred agents: approved to finish pre‑existing treatment started prior to policy effective date (1/1/2022) or considered case‑by‑case.
Documentation required for prior authorization
Submit documentation that the prescriber is enrolled as a billing provider or an ordering, prescribing, or referring (OPR) provider with Rhode Island Medicaid, and include a treatment plan listing medication name, dose, and duration. Include history of prior Hepatitis C treatment when requesting a non‑preferred medication and agree to submit post‑treatment viral load data if requested. Genotyping is not required for Mavyret® or Vosevi®; genotyping is required for requests for non‑preferred, non‑pan‑genotypic medications.
- Prescriber enrollment as billing or OPR provider with Rhode Island Medicaid.
- Treatment plan: medication name, dose, and duration.
- History of prior Hepatitis C treatment if requesting a non‑preferred medication.
- Agreement to submit post‑treatment viral load data if requested.
- Genotyping not required for Mavyret® or Vosevi®; required for non‑preferred, non‑pan‑genotypic agents.
Clinical rationale required for non‑preferred agents
For non‑preferred medication requests, include clinical documentation that justifies the need for an alternative agent; prior approvals for non‑preferred agents are limited to completing therapy started before the policy effective date or will be reviewed on a case‑by‑case basis with supporting clinical rationale.
- Clinical documentation must explain why a preferred agent (Mavyret® or Vosevi®) is not appropriate.
- Requests to continue non‑preferred therapy already in progress (started before 1/1/2022) will be approved to complete the cycle.
Definitions and Eligibility
Clinical Background
Hepatitis C is a major cause of chronic liver disease and is associated with significant comorbidities including hepatocellular carcinoma, the need for liver transplantation, and death. These guidelines exist to define which beneficiaries are eligible for treatment and the documentation required to evaluate coverage under Rhode Island Medicaid.
All patients with documented Hepatitis C Stages 0 through 4 are eligible for treatment under this policy. Treatment decisions aim to reduce progression of liver disease, prevent complications, and achieve sustained virologic response. Because pan‑genotypic preferred agents are available, genotyping is not required for Mavyret® or Vosevi®; genotyping remains required when requesting non‑preferred, non‑pan‑genotypic medications. Prescribers must be enrolled as a billing provider or as an ordering, prescribing, or referring (OPR) provider with Rhode Island Medicaid, and treatment requests must include a treatment plan with medication name, dose, duration, and a history of prior Hepatitis C treatment when requesting a non‑preferred agent. Providers must also agree to submit post‑treatment viral load data if requested.
Revision History
Policy became effective with treatment recommendations and prior authorization rules for Hepatitis C, including preferred agents Mavyret and Vosevi and documentation requirements.
Last review of the policy prior to effective date recorded.
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