CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hepatitis C prior authorization form coverage criteria

Form and instructions for providers to request prior authorization for hepatitis C antiviral therapy for Neighborhood Health Plan of Rhode Island members, including required clinical documentation and specialty pharmacy routing.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHepatitis C prior authorization form coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed PA form and supporting clinical documentation to 1-866-423-0945.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3approved specialty pharmacies listed for dispensing

1fax number for PA submission

6clinical data elements requested on form

Coverage Criteria Overview

Initial prior authorization data

Coverage consideration is based on completion of the following documented items

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Required items for PA review: Provider must supply treatment status (naïve, retreatment, currently on therapy), Hepatitis C genotype, hepatic fibrosis stage with supporting test(s), cirrhosis status (compensated vs decompensated), prior HCV drug therapy with dates, and rationale if unable to use preferred agents Mavyret and/or Vosevi.

If request is for Vosevi, no further information is required.

The PA form does not list any specific policy exclusions on the face of the clinical assessment. It is structured to collect the clinical details needed for review (treatment status, genotype, fibrosis stage, cirrhosis status, prior therapies), and there is no separate section enumerating explicit exclusions.

There are no discrete "Not Medically Necessary" conditions provided on the form. Instead, the form requires submission of supporting clinical documentation (for example, fibrosis staging test results and prior treatment history) and a documented rationale if the prescriber requests an agent other than the preferred therapies. Failure to supply required documentation or to justify use of non-preferred agents may lead to denial.

Provider Requirements and Submission

Prior Authorization

Prior Authorization Required

Prior authorization is required for Hepatitis C treatments. Complete the Neighborhood Health Plan of Rhode Island Hepatitis C Prior Authorization (PA) form in full and submit it with all required clinical documentation for review.

Fax completed PA form and supporting documentation to: 1-866-423-0945.
Pharmacy prescriptions should be routed per the PA form instructions; Limited Specialty Pharmacy Network applies. Fax prescriptions to one of the following specialty pharmacies: Care New England Specialty Pharmacy (Fax: 401-889-5050), CVS Specialty Pharmacy (Fax: 800-323-2445), or Lifespan Specialty Pharmacy (Fax: 401-444-4095).
For pharmacy department questions: 1-401-427-8200.

Documentation Required

Required Clinical Documentation and Denial Risk

Clinical documentation must be submitted with the PA request. Failure to provide required documentation or to justify why preferred agents cannot be used may result in denial of the request.

Required supporting documentation includes: treatment status (treatment-naïve or retreatment), prior HCV drug therapy and dates, and current therapy start date if applicable.
Hepatitis C genotype and hepatic fibrosis staging must be documented (stage 0–4).
Tests used to determine disease stage must be submitted (APRI, Fibroscan, Fibrotest, imaging, or liver biopsy with METAVIR score).
If cirrhosis is present, document compensated vs decompensated status.
Provide rationale and supporting clinical documentation if requesting an agent other than preferred therapies (Mavyret and/or Vosevi).

Denial Risk

Preferred Agent Requirement and Documentation-Related Denials

When requesting alternatives to preferred agents, document a clear clinical rationale why Mavyret and/or Vosevi cannot be used (e.g., prior intolerance, documented treatment failure, drug–drug interaction, or genotype-specific considerations). If this rationale and supporting evidence are not provided, the request may be denied.

If request is for Vosevi, no further information is required on treatment status per form instructions.
Include prior treatment details (drug name(s), dates, and reason for discontinuation such as side effects or inadequate response).
Prescriber must indicate whether they agree to submit post-treatment viral load data.

Note

Submission Instructions

Instructions: Please complete and fax the Hepatitis C PA form and all applicable documentation directly to Neighborhood Health Plan of Rhode Island at 1-866-423-0945 for review. Follow the PA form directions for routing pharmacy prescriptions to the Limited Specialty Pharmacy Network.

Fax prescription and PA form to one of the specialty pharmacies listed on the form: Care New England Specialty Pharmacy (Fax: 401-889-5050), CVS Specialty Pharmacy (Fax: 800-323-2445), or Lifespan Specialty Pharmacy (Fax: 401-444-4095).
If additional questions, contact Pharmacy Dept: 1-401-427-8200.

Initial Therapy Requirements

Initial therapy requirements

Initial therapy requests

Initial therapy info: Document treatment-naïve vs retreatment, HCV genotype, hepatic fibrosis stage with supporting test (APRI, Fibroscan, Fibrotest, imaging, or liver biopsy with METAVIR score), cirrhosis status (compensated vs decompensated), and provide rationale with clinical documentation if unable to use preferred agents Mavyret and/or Vosevi.

If request is for Vosevi, no further information is required.

Continuation Therapy Documentation

Continuation therapy documentation

For members currently on therapy

Continuation info: If currently on therapy, provide therapy start date and list previous Hepatitis C drug therapy with dates; prescriber may be asked to submit post-treatment viral load data.

Documentation supporting fibrosis staging should still be provided when applicable.

Step Therapy and Preferred Agent Bypass

Requirement	Details
Step therapy requirement	Prescriber must document rationale why member is unable to use preferred HCV agents Mavyret and/or Vosevi; clinical documentation must be provided to support the rationale.
Documentation types	Documentation supporting hepatic fibrosis staging (APRI, Fibroscan, Fibrotest, imaging, or liver biopsy with METAVIR score) and prior HCV therapy details should be submitted with the PA request.
Form note	If request is for Vosevi, no further information is required.

Specialty Pharmacy / Site of Dispense

Billing Rule

Use Limited Specialty Pharmacy Network for dispensing

Dispensing must occur through the Limited Specialty Pharmacy Network; prescriptions should be routed to one of the listed specialty pharmacies (Care New England Specialty Pharmacy, CVS Specialty Pharmacy, or Lifespan Specialty Pharmacy).

Care New England Specialty Pharmacy — Fax: 401-889-5050
CVS Specialty Pharmacy — Fax: 800-323-2445
Lifespan Specialty Pharmacy — Fax: 401-444-4095

Key Definitions

Treatment naïve definition

DefinitionPatient who has not previously received HCV antiviral therapy.

How identified on PA formChecked box labeled 'Treatment naïve' in the Clinical Assessment section.

Documentation requiredNo prior HCV drug history required; provide current clinical data (genotype, fibrosis stage, cirrhosis status) as part of PA submission.

Retreatment definition

DefinitionPrior treatment failure with another HCV agent (i.e., patient previously treated but did not achieve adequate response).

How identified on PA formChecked box labeled 'Retreatment (prior treatment failure with another HCV agent)' in the Clinical Assessment section.

Documentation requiredProvide previous Hepatitis C drug therapy names and dates and indicate reason (side effect, inadequate response, or other).

Background and Purpose

The form gathers the essential clinical data to determine appropriate hepatitis C antiviral therapy: treatment status (treatment-naïve, retreatment, or currently on therapy with start date), HCV genotype, hepatic fibrosis stage with the supporting test(s) used (APRI, Fibroscan, Fibrotest, imaging, or liver biopsy with METAVIR score), and cirrhosis status (compensated or decompensated). It also requests prior hepatitis C drug names and dates, whether the prescriber will submit post-treatment viral load data, and a required rationale and documentation if the member cannot use preferred agents Mavyret and/or Vosevi.