CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hepatitis C Prior Authorization Form - Coverage Criteria

Form and instructions for prescribers to request prior authorization of Hepatitis C medications for members of Neighborhood Health Plan of Rhode Island; applies to prescribers and pharmacies submitting PA requests.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHepatitis C Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative — form/instructions (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the signed prior authorization form with required clinical documentation (including fibrosis staging and prior HCV therapy dates) to 1-866-423-0945.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-423-0945fax number for PA submission

3designated specialty pharmacies

1-401-427-8200Pharmacy Dept phone

Dec 2022form update date

Coverage Criteria

General PA criteria

Coverage depends on completion of the PA form with documentation of the following as applicable

Core PA requirements: Completed and signed prior authorization form; submission via fax to payer with all applicable documentation; documentation of hepatic fibrosis staging test(s) (e.g., APRI, Fibroscan, Fibrotest, imaging, or liver biopsy with METAVIR score) and prior Hepatitis C drug therapy dates when applicable; documentation of treatment status (treatment‑naïve, retreatment, currently on therapy with start date, side effect, inadequate response, or other)

If request is for Vosevi, no further information is required per form

Non-preferred agent criteria

When requesting non-preferred HCV agents

Non-preferred agent justification: Provide a rationale and supporting clinical documentation demonstrating the member is unable to use preferred agents Mavyret and/or Vosevi

Clinical documentation must be provided; include prior therapy history, adverse reactions, inadequate response, or other clinically relevant justification

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHepatitis C Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative — form/instructions (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the signed prior authorization form with required clinical documentation (including fibrosis staging and prior HCV therapy dates) to 1-866-423-0945.

SourceLink

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Provider Actions & Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Hepatitis C treatment. Complete and fax the prior authorization form, signed by the prescriber, with all applicable clinical documentation to Neighborhood Health Plan of Rhode Island at 1-866-423-0945 for review. Limited Specialty Pharmacy Network applies; fax specialty pharmacy prescriptions to an approved specialty pharmacy (Care New England Specialty Pharmacy, CVS Specialty Pharmacy, or Lifespan Specialty Pharmacy) as listed on the PA form.

Fax PA form and documentation to: 1-866-423-0945
Specialty pharmacy contact options: Care New England Specialty Pharmacy (Fax: 401-889-5050), CVS Specialty Pharmacy (Fax: 800-323-2445), Lifespan Specialty Pharmacy (Fax: 401-444-4095)
Pharmacy Dept Phone: 1-401-427-8200

Note

Vosevi Exception

If the request is for Vosevi, no further clinical information is required on the PA form; submit the PA form per instructions and indicate Vosevi on the treatment status section.

Documentation Required

Required Clinical Documentation

Provide required clinical documentation to support treatment decision and disease staging. Documentation of the test(s) used to determine hepatic fibrosis stage must be submitted with the PA request.

Acceptable tests: AST to Platelet Ratio Index (APRI), Fibroscan score, Fibrotest score, relevant imaging study, or liver biopsy indicating METAVIR score
Document whether cirrhosis is present and if so whether it is compensated or decompensated
If applicable, provide prior Hepatitis C drug therapy (drug name(s) and dates) and current therapy start date

Documentation Required

Preferred Agent Requirement

When requesting a non-preferred agent, the prescriber must provide a rationale and supporting clinical documentation explaining why the member is unable to use preferred HCV agents (Mavyret and/or Vosevi).

Include clinical reasons such as prior intolerance, contraindication, documented treatment failure, or other clinically relevant justification
Provide supporting records (progress notes, labs, prior authorization denials, adverse event documentation) with the PA submission

Definitions

Treatment status

Treatment-naïvePatient has not previously received Hepatitis C antiviral therapy

Retreatment (prior treatment failure)Patient is undergoing retreatment due to prior treatment failure with another HCV agent

Currently on therapyPatient is currently receiving HCV therapy — prescriber must provide therapy start date

Side effect / Inadequate responseRequest indicates prior therapy discontinued for side effects or inadequate response; provide previous drug(s) and dates

OtherFree-text option for other treatment status details as specified by prescriber on the form

Hepatic fibrosis stage

Stage 0-4Hepatic fibrosis staged from 0 through 4, with Stage 4 indicating cirrhosis

Documentation methodsAcceptable tests: APRI, Fibroscan score, Fibrotest score, imaging study, or liver biopsy with METAVIR score — documentation must be submitted with PA

Cirrhosis presenceForm asks whether cirrhosis is present and, if yes, to indicate compensated or decompensated status

Other testOption to specify other test used to determine disease stage (free-text)

OpenPayer

Hepatitis C Prior Authorization Form - Coverage Criteria

Coverage Criteria

Provider Actions & Submission Instructions

Definitions

Background