Starting October 1, 2019, the Michigan Department of Health and Human Services (MDHHS) expanded Medicaid coverage of direct-acting antivirals (DAAs) for eligible Medicaid beneficiaries with a Metavir fibrosis score of F0 or above for treatment of chronic hepatitis C infection.
While Medicaid coverage has expanded to treat beneficiaries without fibrosis, the following Prior Authorization Criteria continue to apply for treatment of Medicaid beneficiaries for chronic hepatitis C infection:
- DAAs must be prescribed by a gastroenterologist, hepatologist, liver transplant or infectious disease physician. If the prescribing provider is not one of the identified specialists noted, the prescriber must submit documentation of consultation/collaboration of the specific case with one of the aforementioned specialists which reflects discussion of the history and agreement with the plan of care with the date noted in the progress note.
- Documentation of the patient’s use of illegal drugs or abuse of alcohol must be noted (i.e., current abuse of IV drugs or alcohol or abuse within the past six months) for the sole purpose of optimizing treatment.
- Documentation of the patient’s commitment to the planned course of treatment and monitoring (including SVR 12) as well as patient education addressing ways to reduce the risks for re-infection must be submitted.
MDHHS has amended its Prior Authorization Criteria and Request Form (or “DAA Approval Form”) to reflect the changes in Medicaid treatment coverage. To access the new forms, please visit Michigan.magellanrx.com/provider. The Hepatitis C Prior Authorization Criteria document can be found under “Documents” and the Hepatitis C Prior Authorization Request Form can be found under “Forms.”