Hepatitis C Treatment Coverage and PDL Update Scheduled for January 1

Date: December 20, 2022

Attention: All Providers

Effective date: January 1, 2023

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: On January 1, 2023, the Texas Health and Human Services Commission (HHSC) will designate one medication as the preferred direct-acting antiviral (DAA) drug option for treating Hepatitis C infection.  HHSC will designate all other DAA drugs on the Medicaid formulary as non-preferred. Managed care organizations like Texas Children’s Health Plan are required to follow HHSC’s preferred drug list (PDL). 

How this impacts providers: All Medicaid clients are eligible for DAA treatment with the primary preferred agent regardless of the client’s METAVIR fibrosis score, and prior authorization (PA) is not required.  Any enrolled Medicaid provider can prescribe the preferred drug, and a drug screening is not required.

Any active members taking Epclusa/Voesvi will need to be switched to Mavyret. Providers must follow these next steps:

1. The only exceptions to continue non-preferred agents Eplucsa or Vesvi are if the member has treatment failure, contraindication, allergic reactions to Mavyret. Providers can also submit an exception request if the member has stage-4 cancer.
2. If members meet the exception criteria, providers may submit a prior authorization request form to Navitus (see link here).
3. If providers do NOT submit a new prescription for Mavyret, members will have their refill claims rejected at the point of sale for “Prior Authorization” required (PDL).
4. If the member does not have any of the exceptions above, but providers still feel it is medically necessary to stay on the non-preferred agent, providers may appeal the PDL prior authorization denial for medical necessity.
5. Additionally, effective January 1, the following clinical prior authorization forms for Hepatitis C treatment agents will be retired and no longer necessary:
6. Antiviral Agents for Hepatitis C Virus – Initial Request (HHS Form 1335)
7. Antiviral Agents for Hepatitis C Virus – Initial Request – Addendum (HHS Form 1342)

Next steps for providers: Providers should notify their members of the medication therapy change and submit new prescriptions to the pharmacy for Mavyret before January 1. If the member meets criteria to obtain a non-preferred product, the provider must submit a PDL prior authorization request as quickly as possible to avoid delay of care. If the member does not meet the exception criteria, the provider must submit an appeal and provide medical necessity rationale before January 1.  

If you have any questions, please email TCHP Pharmacy at: TCHPPharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.

For access to the PDL Hepatitis C prior authorization form: Log into the Navitus provider portal, or visit txstarchip.navitus.com, click “Prior Authorization Forms”, and select the “Hep C Agents (PDL)” prior authorization request.