CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid_Hep_C_Global_20250625

Defines coverage, authorization, documentation, quantity limits, and continuity rules for hepatitis C antiviral agents for Rhode Island Medicaid beneficiaries, with preferred status for Mavyret and conditional coverage for Vosevi and other agents.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Hep_C_Global_20250625

Policy CodePolicy N/A

Change Typeclarified

Effective DateAug 1, 2021

Next Review Date

Key ActionPrescribers must be enrolled as a billing provider or an ordering, prescribing or referring (OPR) provider with Rhode Island Medicaid.

SourceLink

POLICY UPDATE CHANGES

Preferred agents listed as Mavyret and Vosevi; non-preferred agents listed and require authorization.

2Preferred Agents

4Non-Preferred Agents requiring authorization

365Vosevi no-authorization lookback (days)

3Mavyret daily tablets

Coverage Summary

Rhode Island Medicaid has a mixed coverage stance for oral direct-acting antivirals (DAAs) for Hepatitis C: Mavyret (glecaprevir/pibrentasvir) is designated as a preferred agent and requires no prior authorization, while Vosevi (sofosbuvir/velpatasvir/voxilaprevir) is also listed as preferred but has a conditional coverage posture (it may require authorization except in specified salvage or lookback circumstances). Non-preferred agents (for example Epclusa, Harvoni, Sovaldi, Zepatier) require prior authorization.

Operational rules support this mixed posture: prescribers must be enrolled with Rhode Island Medicaid, beneficiaries with documented Hepatitis C stages 0–4 are eligible, and approvals from prior publicly funded delivery systems are honored to maintain continuity of treatment during transitions between systems.

Criteria for Approval

Covered when ALL of the following are met:

ALL of the following

Prescriber enrollment
- Prescriber is enrolled as a billing provider or an ordering, prescribing or referring (OPR) provider with Rhode Island Medicaid
Beneficiary HCV stage
- Beneficiary has documented Hepatitis C Stages 0 through 4
Documentation / Authorization rules
- Mavyret: Prior Authorization is not required
- Vosevi salvage: Prior Authorization is not required for Vosevi when used as a salvage medication after prior treatment failure; see package insert for FDA approved indication and prescribing information
- Vosevi lookback: Vosevi will be covered with no authorization if there is at least one paid claim for an HCV agent within the last 365 days>= 1 paid claim in last 365 days
- Non-preferred agents: Treatment request for non-preferred medications require genotyping and prior authorization with clinical documentation of need for an alternative, non-preferred agent
Transition / Continuity
- Continuity of Treatment: Approvals by a prior publicly funded delivery system will be honored for the portion of treatment remaining after transitioning between Fee-for-Service Medicaid, Managed Care Medicaid, or Department of Corrections and Medicaid Program
Policy exceptions
- Completion of prior therapy: Will be approved if patient is completing a cycle of therapy initiated prior to current policy implementation date

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Preferred Status & Authorization by Agent

Preferred Status / Authorization Requirements

Agent-specific coverage stance and authorization requirements:

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Applicable Codes / Drug Products Mentioned

HCPCS/NDC/Drug products mentionedmixed

	Mavyret (glecaprevir and pibrentasvir) – preferred, no authorization; quantity limit: 100-40mg tablet: 3 tablets per day.
	Vosevi (sofosbuvir, velpatasvir, and voxilaprevir) – preferred, authorization may be required; no prior authorization required when used as salvage medication after prior treatment failure or if there is at least one paid claim for an HCV agent within the last 365 days; quantity limit: 1 per day.
	Epclusa (sofosbuvir and velpatasvir) – non-preferred, authorization required; quantity limit: 1 per day.
	Harvoni (ledipasvir and sofosbuvir) – non-preferred, authorization required; quantity limit: 1 per day.
	Sovaldi (sofosbuvir) – non-preferred, authorization required; quantity limit: 1 per day.
	Zepatier (elbasvir and grazoprevir) – non-preferred, authorization required; quantity limit: 1 per day.

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization requirements for non-preferred agents

Prior authorization is required for non-preferred HCV agents (Epclusa, Harvoni, Sovaldi, Zepatier). PA requests must include clinical documentation explaining the medical necessity of the alternative agent and must include genotyping results.

Genotyping is required for non-preferred medication requests
PA must include clinical documentation of need for an alternative, non-preferred agent

Documentation Required

Prescriber enrollment requirement

Prescribers must be enrolled as a billing provider or as an ordering, prescribing, or referring (OPR) provider with Rhode Island Medicaid.

Documentation Required

Required treatment documentation

Include the patient’s history of prior Hepatitis C treatment when relevant, a treatment plan specifying medication name, dose, and duration, and an agreement to submit post-treatment viral load data if requested.

Documentation Required

Genotyping requirement

Genotyping is not required for Mavyret or Vosevi. Genotyping is required when requesting non-preferred medications.

Billing Rule

Quantity limits

Adhere to the policy’s daily quantity limits for each product (see policy): Mavyret 100–40 mg tablets — 3 per day (or 50–20 mg pak oral pellets — 6 per day for ages 3–17); Vosevi, Epclusa, Harvoni, Sovaldi, and Zepatier — 1 per day.

Prior Authorization

Vosevi salvage use exception

Vosevi may be prescribed without prior authorization when used as a salvage medication after prior treatment failure per the FDA-approved indication in the package insert. Additionally, Vosevi will be covered with no authorization if there is at least one paid claim for an HCV agent within the last 365 days.

See FDA prescribing information/package insert for Vosevi indication
No-authorization lookback: ≥1 paid HCV claim within the last 365 days

Documentation Required

Continuity of treatment

When beneficiaries transition between publicly funded delivery systems (Fee-for-Service, Managed Care, or Department of Corrections), any medication approval by the prior delivery system will be honored for the portion of treatment that remains.

Policy Background

Rhode Island Medicaid policy governs coverage of oral DAAs for Hepatitis C with specific preferred agents and operational rules for authorization, documentation, and continuity of care. Mavyret is preferred and does not require prior authorization; Vosevi is preferred but may require authorization except when used as a salvage medication after prior treatment failure or when there is at least one paid claim for an HCV agent within the last 365 days.

Prescribers must be enrolled as a billing or OPR provider with Rhode Island Medicaid. Beneficiaries with documented Hepatitis C stages 0 through 4 are eligible. Neither Mavyret nor Vosevi require genotyping; genotyping is required when requesting non-preferred medications. Prior authorization requests for non-preferred agents must include clinical documentation of need, genotyping, history of prior Hepatitis C treatment if relevant, and a treatment plan specifying medication name, dose, and duration. Providers must agree to submit post-treatment viral load data if requested.

Quantity limits and continuity: Mavyret dosing limits include 3 tablets per day (100/40 mg tablets) (and pediatric pak limits where specified); Vosevi and other listed agents have a 1 per day limit. Approvals by a prior publicly funded delivery system will be honored for the remaining portion of treatment when beneficiaries transition between delivery systems.

Key thresholds & quick facts

Vosevi paid-claim lookback>= 1 paid claim for an HCV agent within the last 365 days

Mavyret daily quantity limit3 x 100/40 mg tablets per day

Vosevi daily quantity limit1 per day (Vosevi)

Effective date2021-08-01

Last review2023-05

Revision History

2021-08-01policy_effective

Policy effective date establishing treatment recommendations: preferred agents Mavyret and Vosevi; non-preferred agents require authorization. Treatment recommendations as of August 1, 2021.

2021-06review

Policy reviewed (06/2021) with no material clinical policy changes noted in revision history.

2022-02review

Policy reviewed (02/2022) with no material clinical policy changes noted in revision history.

2022-04review

Policy reviewed (04/2022) with no material clinical policy changes noted in revision history.

2023-05reviewLatest

Policy reviewed (05/2023) with no material clinical policy changes noted in revision history.

OpenPayer

Medicaid_Hep_C_Global_20250625

Coverage Summary

Preferred Status & Authorization by Agent

Applicable Codes / Drug Products Mentioned

Provider Actions & Authorization Requirements

Clinical Evidence & References

Definitions

Policy Background

Revision History