CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hepatitis C antiviral coverage (direct-acting antivirals)

Defines coverage, prior authorization, quantity limits, and documentation requirements for Hepatitis C direct-acting antivirals (preferred and non-preferred) for Rhode Island Medicaid beneficiaries and enrolled prescribers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHepatitis C antiviral coverage (direct-acting antivirals)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2021

Next Review DateN/A

Key ActionPrescribers must be enrolled with Rhode Island Medicaid and include required documentation (medication name, dose, duration, prior treatment history) when requesting non-preferred agents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Preferred agents

5Non-preferred agents

SpecifiedQuantity limits

0-4Eligible stages

Coverage and Medical Necessity Criteria

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Initial Therapy and Authorization Criteria

Covered when ALL of the following are met

Prescriber enrollment: Prescriber is enrolled as a billing provider or as an ordering, prescribing or referring (OPR) provider with Rhode Island Medicaid.

Beneficiary eligibility: Patient has documented Hepatitis C Stages 0 through 4.

Agent selection and prior authorization rules: Mavyret requires no prior authorization; Vosevi may be covered without authorization if there is at least one paid claim for an HCV agent in the prior 365 days or when used as salvage after prior treatment failure; non-preferred agents (Epclusa, Harvoni, Sovaldi, Zepatier) require prior authorization with clinical documentation of need for an alternative.

Required documentation: Treatment plan including medication name, dose and duration; history of prior Hepatitis C treatment if relevant; agreement to submit post-treatment viral load data if requested. Genotyping is not required for Mavyret or Vosevi but is required for treatment requests for non-preferred medications.

Drug Codes, Dosing & Quantity Limits

Preferred, No AuthorizationNDC | mixedCovered

Mavyret

glecaprevir and pibrentasvir

Preferred, Authorization may be requiredNDC | mixedCovered

Vosevi

sofosbuvir, velpatasvir, and voxilaprevir

Non-Preferred, Authorization RequiredNDC | mixed

Epclusa	sofosbuvir and velpatasvir
Harvoni	ledipasvir and sofosbuvir
Sovaldi	sofosbuvir
Zepatier	elbasvir and grazoprevir

Mavyret pediatric pak dosing

DrugMavyret (50-20 mg pak, oral pellets)

Quantity limit6 per day

Age rangeAges 3-17

Mavyret adult tablet dosing

DrugMavyret (100-40 mg tablet)

Quantity limit3 tablets per day

Strength100-40 mg per tablet

Other DAAs dosing

DrugsVosevi, Epclusa, Harvoni, Sovaldi, Zepatier

Quantity limit1 per day

Dose formPer policy quantity limit applies to each listed DAA (one unit per day)

Prior Authorization, Documentation & Billing Actions

Prior Authorization

Prior authorization requirements

Mavyret does not require prior authorization; Vosevi does not require prior authorization when used as salvage after prior treatment failure. All other non-preferred agents (Epclusa, Harvoni, Sovaldi, Zepatier) require prior authorization with clinical justification.

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.
Non-preferred agents require prior authorization with clinical documentation of need for an alternative agent.

Step Therapy

Coverage tied to recent HCV therapy

Vosevi will be covered without authorization if there is at least one paid claim for an HCV agent within the prior 365 days. Mavyret is a preferred agent and does not require prior authorization.

Vosevi coverage without authorization requires at least one paid claim for an HCV agent within the last 365 days.
Mavyret is preferred and does not require prior authorization.

Documentation Required

Documentation and prescriber enrollment

Prescribers must be enrolled as a billing provider or an ordering/prescribing/referring (OPR) provider with Rhode Island Medicaid. Required documentation includes history of prior HCV treatment if relevant, a treatment plan with medication name, dose and duration, and agreement to submit post-treatment viral load data if requested. Genotyping is required for requests for non-preferred medications.

Prescriber enrollment as a billing or OPR provider with Rhode Island Medicaid is required.
Include history of prior Hepatitis C treatment when relevant.
Include treatment plan: medication name, dose, and duration, and agree to submit post-treatment viral load data if requested.
Genotyping is required for treatment requests for non-preferred medications.

Denial Risk

Non-preferred agent prior authorization risk

Requests for non-preferred agents will be reviewed on a case-by-case basis; prior authorization must include clinical documentation demonstrating the need for an alternative, non-preferred agent.

Prior Authorization requests for non-preferred agents must include clinical documentation of medical necessity.

Policy Scope & Background

This policy addresses treatment of Hepatitis C virus infection for beneficiaries with documented disease stages 0 through 4 and aligns coverage with FDA-approved indications as referenced in package inserts. Preferred regimens are identified (Mavyret and Vosevi); Mavyret does not require prior authorization, and Vosevi may be covered without prior authorization when used as salvage after prior treatment failure or when there is at least one paid claim for an HCV agent in the prior 365 days. Non-preferred agents require prior authorization and clinical justification, and the policy specifies documentation requirements including prescriber enrollment, history of prior HCV treatment when relevant, a treatment plan with medication name, dose and duration, and agreement to submit post-treatment viral load data if requested.

Beneficiary & Prescriber Definitions

Eligible beneficiaries

Eligible populationBeneficiaries with documented Hepatitis C Stages 0 through 4

Coverage stanceTreatment of HCV across stages 0-4 is eligible for coverage when criteria met

Related requirementPrescriber must be enrolled with Rhode Island Medicaid (billing or OPR)

Prescriber enrollment

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

Applies toAll prescribers requesting HCV antiviral coverage under Rhode Island Medicaid

Documentation notePrescriber enrollment is listed among required documentation for approval