No Prior Authorization Required for Most Hepatitis C Medications
Dec 16, 2022, 21:14 PM
Changes to the CareOregon Oregon Health Plan (Medicaid) Formulary
Effective January 1, 2023 most hepatitis C treatments will be covered by Oregon Medicaid (including all CCOs) without requiring prior authorization. Two conditions must be met for this to apply 1) the member must be treatment naïve; AND 2) an Oregon Health Plan preferred drug (Mavyret or generic Eplcusa) is being used within usual quantity limits.
Preferred Hepatitis C Drugs
- Mavyret - Most situations clinically only require 8 weeks. Up to 16 weeks is available without PA.
- Generic Epclusa - Most situations clinically only require 12 weeks, but up to 24 can be received without PA.
Definition of Treatment Naïve
- The claims system will look for any evidence of a previous course of therapy with a protease inhibitor.
- Note: In some cases (such as reinfection or limited first treatment course), it may be clinically appropriate for a second course to be approached as treatment naïve. However, prior authorization will be required if claims see a past treatment.
Case Management
- Will be required if PA is required (optional if PA is not needed). Use the Hepatitis C Prior Authorization Request form, which can be found under the Pharmacy Resources page on our website.
- Use the Hepatitis C Case Management Request form for optional case management requests. This form is also available under Pharmacy Resources.
Your office should have received a fax from CareOregon regarding the above information. If you did not receive it, you can download it here.