CurrentUnitedHealthcarePolicy N/A

Maryland Medicaid Hepatitis C Therapy Prior Authorization form

A Maryland Medicaid Hepatitis C treatment prior authorization form capturing patient demographics, diagnosis confirmation, genotype, fibrosis/cirrhosis status, prior HCV treatment history, baseline labs, co-infections, transplant status, and provider attestation required for authorization of HCV drug therapy.

Policy Summary

PayerUnitedHealthcare

PolicyMaryland Medicaid Hepatitis C Therapy Prior Authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the completed Maryland Medicaid Hepatitis C Therapy Prior Authorization Form with required attachments (genotype, biopsy/fibrosis results, baseline HCV RNA, lab values as applicable) or the form will be returned; contact phone 800-310-6826, fax 866-940-7328.

POLICY UPDATE CHANGES

No material clinical/coverage changes.

1Form type

MultipleRequired attachments

ConditionalLab timing requirements

Coverage Summary

This document is a Maryland Medicaid Hepatitis C Therapy Prior Authorization form used to request approval for HCV antiviral treatment. Authorization is covered with criteria — requests will be reviewed when the required form and supporting documentation are submitted and all specified clinical criteria are met.

What providers must do

Prior Authorization

Submit completed prior authorization form

Providers must submit the completed Maryland Medicaid Hepatitis C Therapy Prior Authorization Form with required attachments (genotype, biopsy/fibrosis results, baseline HCV RNA, lab values as applicable). Incomplete forms will be returned. For questions or submission, contact the Maryland Medicaid Pharmacy Program.

Phone: 800-310-6826
Fax: 866-940-7328

Documentation Required

Attach required lab and test results

Attach copies of relevant diagnostic and laboratory documents to support the authorization request.

Liver biopsy results (if performed) — include test date and copy of results
HCV genotype and subtype results (pre- and post-transplant genotype if applicable)
Fibrosis test results with test type, date, Metavir grade and stage (if performed)
Baseline HCV RNA level within 180 days prior to treatment (within 90 days for cirrhotic patients)
For cirrhotic patients: total bilirubin, albumin, and INR
If regimen includes ribavirin: hemoglobin, hematocrit, and platelet count

Documentation Required

Document prior HCV treatment history and outcomes

Record the patient’s prior Hepatitis C treatment history including prior regimens, treatment durations/dates, and outcomes.

List prior HCV regimen(s)
Provide treatment duration and dates for each regimen
Document treatment outcomes: Relapsed, Partial Responder, Non-Responder, Toxicities, or Reinfection

Documentation Required

Provide co-infection and transplant information

Document co-infection and transplant status relevant to treatment decisions.

HIV co-infection status (include date drawn if available)
HBV co-infection status; if HBV positive provide HBV viral load and date drawn
Solid organ transplant status — specify transplant type and date

Documentation Required

Provider attestation and signature

Prescriber must sign and date the form attesting that the benefits of treatment outweigh the risks and that the information provided is true and accurate. Electronic signatures are acceptable and are considered original.

Prescriber signature and printed name
Date of signature
Telephone and practice specialty (as requested on form)

Background

This Maryland Medicaid Hepatitis C Therapy Prior Authorization form collects clinical and laboratory information to evaluate and approve HCV antiviral therapy. The form captures confirmation of diagnosis (including documentation that Hepatitis C has been present for ≥ 6 months), HCV genotype and subtype (including pre- and post-transplant genotype if applicable), liver disease staging (no cirrhosis, compensated cirrhosis, decompensated liver disease), results of liver biopsy or fibrosis testing, prior hepatitis C treatment history and outcomes, baseline HCV RNA and other laboratory values, HIV and HBV co-infection status, and solid organ transplant details.

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Policy Summary

PayerUnitedHealthcare

PolicyMaryland Medicaid Hepatitis C Therapy Prior Authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

Maryland Medicaid Hepatitis C Therapy Prior Authorization form

Coverage Summary

Authorization prerequisites (Medical Necessity)

What providers must do

Background

Revision History