CurrentHarvard Pilgrim Health CarePolicy N/A

Massachusetts Standard Prior Authorization Form for Hepatitis C (HCV) Medications

This document is a standardized Massachusetts prior authorization request form for hepatitis C (HCV) medications used by Harvard Pilgrim Health Plan and guides what clinical and administrative information prescribers must supply for PA decisions.

Policy Summary

PayerHarvard Pilgrim Health Care

PolicyMassachusetts standard prior authorization form for hepatitis C medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Massachusetts Hepatitis C medication prior authorization form (fax 617-673-0988 or via online portal) including required clinical fields and prescriber information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18HCV drugs listed on form

B18.2Diagnosis option

F0-F4Fibrosis stages

3 rangesGFR categories

HIV & transplantComorbidity fields

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Coverage Criteria and Medical Necessity Requirements

Information required for medical necessity review

Authorization will be considered when ALL of the following are provided and applicable:

Essential administrative info: Completed prescriber identification including prescriber name, phone, specialty, secure fax, NPI (and DEA if provided), prescriber point of contact if different, and prescriber signature/date.

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Medication and therapy details: Specific HCV medication requested (select from the listed options), anticipated or actual start date, requested duration of treatment (weeks), and whether the request is initial or a continuation with weeks remaining.

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Clinical virologic and staging data: Diagnosis (e.g., ICD-10 B18.2 or other), HCV genotype, baseline HCV RNA with date, stage of hepatic fibrosis (F0–F4) with assessment method and result, and GFR category (0–14, 15–29, or 30 or greater).

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Special clinical considerations: HIV coinfection status, post-liver transplant status, and drug-specific requirements (for example, confirmation for Zepatier that the patient does not have genotype 1a with a baseline NS5A polymorphism).

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Prior treatment history: Documentation of previous HCV treatments including drug name, dates of treatment, response (relapse, partial response, null response defined as <2 log reduction in HCV RNA at Week 12), reason for discontinuation or adverse reaction, and any additional details relevant to prior trials.

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Step therapy exceptions: If step therapy applies, provide documentation of contraindication or expected harm from the alternative, clinical rationale that the alternative is expected to be ineffective, prior trial and failure of the alternative (drug name, dates, adverse reaction or inadequate response), or that the member is stable on the current drug and switching would cause harm.

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This Massachusetts standard prior authorization form is used by Harvard Pilgrim to request coverage for hepatitis C medications. Note: Some plans might not accept this form for Medicare or Medicaid requests. Providers should verify plan-specific submission requirements for members with Medicare or Medicaid coverage prior to submission to avoid delays or denial.

Submission, Documentation, and Prescriber Responsibilities

Prior Authorization

Prior authorization submission requirements

Harvard Pilgrim requires a completed Massachusetts standard Hepatitis C medication prior authorization form for all requests. Submit the completed form via secure fax to 617-673-0988 or through the online prior authorization portal at https://point32health.promptpa.com. For urgent or expedited requests, indicate "Expedited Review/Urgent Request" on the form and provide supporting clinical justification.

Fax: 617-673-0988 (secure)
Online Prior Authorization: https://point32health.promptpa.com
Health Plan Phone: 800-708-4414

Step Therapy

Step therapy exception documentation

Documented justification is required to support any step-therapy exception. Provide clear clinical evidence that the required alternative therapy is contraindicated, expected to be ineffective given the member's clinical characteristics, or was previously tried and failed (include dates, duration, and nature of failure). If the member is stable on the requested drug and switching would likely cause harm, document the stability and expected harm from switching.

Describe contraindication or anticipated harm from the alternative drug
Describe why the alternative is expected to be ineffective (clinical rationale)
For prior trials include: drug name, dates/duration of use, and outcome (Adverse Reaction, Inadequate Response, Relapsed, Partial response, Null response, Did not complete)
If stable on current therapy, describe nature of stability and risk of harm if switched

Documentation Required

Required clinical and prescriber information; Incomplete or missing required clinical information

Ensure all required prescriber and clinical fields are completed. Incomplete or missing information commonly causes delays or denials — include complete prescriber identity and contact information, and core clinical data elements about the patient's hepatitis C infection and prior therapy.

Prescriber: name, NPI, specialty, phone, secure fax, DEA (if applicable), prescriber signature and date; prescriber point of contact name, phone, secure fax, email (if different)
Core clinical data: diagnosis (ICD-10), HCV genotype (specify 1, 1a, 1b, 2, 3, 4, 5, 6 or other), stage of hepatic fibrosis (F0–F4 and compensated vs decompensated if F4), method and numeric result of fibrosis assessment (e.g., FibroScan kPa, biopsy, FibroSure), baseline HCV RNA value with date, renal function (GFR range), HIV coinfection status, and liver transplant status
Prior treatment history: list prior HCV treatments with dates, response (relapse, partial, null, discontinued), and any adverse reactions
For certain drugs: documentation of absence of specific resistance-associated polymorphisms (e.g., Zepatier and baseline NS5A polymorphism for genotype 1a) when required
Requested regimen details: drug name, duration (weeks), anticipated or actual start date, and whether prescribed by or in consultation with GI, ID, or hepatology specialist

Key Definitions and Terms

inv-10: Chronic Hepatitis C — documented diagnosis ICD-10 code B18.2 present as an option on the form

ICD-10 diagnosis option presentB18.2 — Hepatitis C (chronic)

Alternate diagnosis field'Other' option provided for non-B18.2 diagnoses

Location on formSection E: Patient Clinical Information — Diagnosis checklist

inv-11: Fibrosis staging — Stage options F0–F4 and acceptable assessment methods (biopsy, FibroScan, APRI, FIB-4) captured on the form

Fibrosis stage options capturedF0, F1, F2, F3, F4 (with F4 subdivided into Compensated or Decompensated)

Accepted assessment methods listedLiver biopsy; Transient elastography (FibroScan); Shear wave elastography; MRE; FibroSure (FibroTest); Echosens Fibrometer; Fibrospect; APRI; Fib-4; Hepascore; Other

Result entryForm provides space to include numeric result(s) (e.g., kPa) for applicable methods

OpenPayer

Massachusetts Standard Prior Authorization Form for Hepatitis C (HCV) Medications

Coverage Criteria and Medical Necessity Requirements

Diagnosis, Codes, and Clinical Coding Elements

Submission, Documentation, and Prescriber Responsibilities

Background

Key Definitions and Terms