Report

Find your state below or click to read our full report.

Discriminatory state Medicaid restrictions

While there have been some improvements in both state Medicaid program transparency and access since 2014, most states still have discriminatory restrictions that keep enrollees from being cured. 

Discriminatory State Medicaid Restrictions Include:

Liver Disease Progression

Requiring that patients reach a certain stage of fibrosis (liver disease), which can be irreversible and cause cancer.

Bans on Former Substance Users

Barring patients with a history of alcohol or substance use.

Prescriber Restrictions

Only allowing certain specialists, who can be difficult to find, to prescribe a cure.

Find your state

Alabama

State of Hepatitis C Medicaid Access:

D+

Liver damage restrictions

Alabama requires at least moderate liver damage (F2 or greater).

Sobriety restrictions

Alabama requires abstinence from drugs and alcohol for at least six months.

Prescriber restrictions

Alabama does not appear to impose any prescriber restrictions.

Recommendations

  • Remove liver damage and sobriety requirements.
Alaska

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Alaska Medicaid does not any liver damage requirements.

Sobriety restrictions

Alaska Medicaid requires screening and a referral to treatment for active alcohol or illicit substance use.

Prescriber restrictions

Alaska Medicaid has no prescriber restrictions except for when a patient has specific clinic criteria.

Recommendations

  • Remove sobriety restriction.
  • Maintain transparency regarding hepatitis C coverage criteria.
Arizona

State of Hepatitis C Medicaid Access:

C+

Liver damage restrictions

Fee-For-Service (FFS) and five Managed Care Organizations (MCOs), Health Choice, Health Net, Care 1st, Mercy Care, and UHC, require a diagnosis of chronic hepatitis C to access treatment. One MCO, University Family Care, does not have publicly available hepatitis C coverage criteria.

Sobriety restrictions

FFS and five MCOs, Health Choice, Health Net, Care 1st, Mercy Care, and UHC, require beneficiaries to be “in remission” for the past three months from the request date of treatment, and those who have had “a substance use disorder within the past 12 months” must engage in a treatment program. One MCO, University Family Care, does not have publicly available hepatitis C coverage criteria.

Prescriber restrictions

Arizona FFS and four MCOs, Health Choice, Health Net, Care 1st, and Mercy Care, require a prescription to be written by or in consultation with a hepatologist, gastroenterologist, or infectious disease specialist. One MCO, UnitedHealthcare Community Plan, requires a specialist to prescribe. One MCO, University Family Care, does not have publicly available hepatitis C coverage criteria.

Recommendations

  • Remove sobriety and prescriber requirements.
  • Improve transparency regarding hepatitis C coverage criteria and ensure parity across FFS and MCO plans.
Arkansas

State of Hepatitis C Medicaid Access:

F

Liver damage restrictions

Arkansas requires severe liver damage (F3 or greater), depending on a patient’s genotype and whether the individual is treatment naïve or experienced.

Sobriety restrictions

Arkansas requires abstinence from drugs and alcohol for at least six months.

Prescriber restrictions

Arkansas requires a specialist, or a provider working under direct supervision of a specialist, to prescribe.

Recommendations

  • Remove liver damage, sobriety and prescriber requirements.
  • Maintain transparency regarding hepatitis C coverage requirements.
California

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Fee-For-Service (FFS) does not have liver damage requirements. A number of Managed Care Organizations (MCOs) have updated their published criteria to reflect no liver damage requirements or otherwise incorporate by reference the applicable California Department of Health Care Services policy: Aetna Better Health of California, Alameda Alliance for Health, California Health and Wellness, CalOptima, CalViva, Central California Alliance for Health, Contra Costa Health Plan, Health Net, Health Plan of San Joaquin, Inland Empire Health Plan, Kaiser Permanente, Kern Family Health Care, Partnership Healthplan of California, San Francisco Health Plan, and Santa Clara Family Health Plan. However, Anthem, Care1st Health Plan, CenCal Health, Community Health Group, Gold Coast Health Plan, Health Plan of San Mateo, LA Care Health Plan, Molina Healthcare of California, and UnitedHealthcare Community Plan of California do not make criteria publicly available.

Sobriety restrictions

FFS and MCOs do not have sobriety requirements. Anthem, Care1st Health Plan, CenCal Health, Community Health Group, Gold Coast Health Plan, Health Plan of San Mateo, LA Care Health Plan, Molina Healthcare of California, and UnitedHealthcare Community Plan of California do not make criteria publicly available.

Prescriber restrictions

FFS and MCOs do not have prescriber requirements.

Recommendations

  • Remove liver damage requirements.
  • Maintain parity across FFS and MCOs and transparency regarding hepatitis C coverage requirements.Require continued parity between the Fee-For-Service (FFS) and Managed Care (MCO) programs ensuring all Medicaid beneficiaries can access treatment.
Colorado

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Effective January 1, 2018, the Fee-For-Service (FFS) and Primary Care Case Management System (PCCM) have no minimum liver damage requirement for accessing treatment. The Managed Care Organization (MCO), Denver Health Medicaid Choice, does not have any liver damage requirements.

Sobriety restrictions

FFS and PCCM require screening and counseling for sobriety; for members abusing/misusing alcohol or controlled substances, members must be receiving or be enrolled in counseling or a substance use treatment program for at least 1 month prior to starting treatment. The MCO (Denver Health Medicaid Choice) also requires screening and counseling for alcohol and substance use.

Prescriber restrictions

FFS and PCCM require a prescription to be written by or in consultation with a specialist. The MCO (Denver Health Medicaid Choice) also requires a prescription to be written by or in consultation with a specialist.

Recommendations

• Remove mandatory counseling or substance use treatment requirement to start treatment or allow simultaneous treatments.
• Remove prescriber requirements.
• Maintain transparency regarding hepatitis C coverage criteria and ensure coverage parity between FFS and MCO programs.

Connecticut

State of Hepatitis C Medicaid Access:

A+

Liver damage restrictions

Connecticut does not impose any liver damage restrictions.

Sobriety restrictions

Connecticut does not impose any sobriety restrictions.

Prescriber restrictions

Connecticut does not impose any prescriber restrictions.

Recommendations

  • Continue to provide access to hepatitis C medications for all Medicaid beneficiaries.
  • Maintain transparency regarding hepatitis C coverage requirements.
Delaware

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Fee-For Service (FFS) does not impose minimum liver damage requirements. One Managed Care Organization (MCO), Highmark Health Options, similarly imposes no minimum liver damage requirement. One MCO, AmeriHealth Caritas, has unclear liver damage requirements.

Sobriety restrictions

FFS requires screening and counseling for substance use. One MCO, Highmark Health Options, also requires screening and counseling for substance use. AmeriHealth requires that patients are alcohol and drug free at the time of authorization request or, if the provider is aware that the patient has a positive drug test or alcohol dependence, the patient is working towards seeking treatments.

Prescriber restrictions

FFS does not appear to impose prescriber restrictions. One MCO, Highmark Health Options, requires a prescription be written by a specialist. AmeriHealth does not request prescriber specialty on its authorization form.

Recommendations

  • Remove sobriety and prescriber restrictions.
  • Ensure parity across FFS and MCOs and ensure transparency regarding hepatitis C coverage criteria.
District of Columbia

State of Hepatitis C Medicaid Access:

B-

Liver damage restrictions

The Fee-For-Service (FFS) program does not impose liver damage restrictions. One Managed Care Organization (MCO), AmeriHealth Caritas, requires at least moderate liver damage (F2 or greater) or a beneficiary to meet other clinical requirements. One MCO, Trusted Health Plan requires a diagnosis of chronic hepatitis C as well as letter of medical necessity. The hepatitis C requirements of one MCO, Amerigroup, are unclear.

Sobriety restrictions

FFS requires a beneficiary to be screened and counseled for alcohol and substance use. One MCO, AmeriHealth Caritas, also requires screening and counseling for alcohol and substance use. One MCO, Trusted Health Plan, requires a beneficiary to agree to abstain from illicit drug or alcohol use for at least six months and, if not, to give the reason. The hepatitis C requirements of one MCO, Amerigroup, hepatitis C requirements are unclear.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. One MCO, AmeriHealth Caritas, requires a prescription to be written by a specialist. One MCO, Trusted Health Plan, requests a specialist to “supervise” a beneficiary undergoing treatment. The hepatitis C requirements of one MCO, Amerigroup, are unclear.

Recommendations

• Remove sobriety and prescriber restrictions.
• Require coverage parity across the FFS and MCO program and ensure transparency regarding coverage criteria for hepatitis C medications.

Florida

State of Hepatitis C Medicaid Access:

B+

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require a diagnosis of hepatitis C. Neither imposes liver damage requirements.

Sobriety restrictions

FFS and MCOs require one-month sobriety prior to initiating treatment.

Prescriber restrictions

FFS and MCOs require a prescription be written by or in consultation with a specialist.

Recommendations

  • Remove sobriety and prescriber restrictions.
  • Maintain hepatitis C coverage parity between FFS and MCO programs and transparency regarding prior authorization requirements.
Georgia

State of Hepatitis C Medicaid Access:

C

Liver damage restrictions

Fee-For-Service (FFS) does not have any liver damage requirements. One Managed Care Organization (MCO), Amerigroup Community Care, also does not have any liver damage requirements. One MCO (WellCare of Georgia) appears to require severe liver damage (F3 or greater). Two MCOs (Peach State Health Plan and CareSource) do not have publicly available information.

Sobriety restrictions

FFS requires a patient to enroll in a substance use program if the individual is currently using alcohol or intravenous drugs. One MCO (Amerigroup Community Care) has the same requirement. One MCO (WellCare of Georgia) considers patients with active substance or alcohol use on a case-by-case basis and in coordination with a substance treatment specialist. Two MCOs (Peach State Health Plan and CareSource) do not have publicly available information.

Prescriber restrictions

FFS does not have any prescriber restrictions. One MCO (Amerigroup Community Care) also does not have any prescriber restrictions. One MCO (WellCare of Georgia) appears to require a prescription be written by or in consultation with a specialist. Two MCOs (Peach State Health Plan and CareSource) do not have publicly available information.

Recommendations

  • Eliminate liver damage, sobriety and prescriber restrictions.
  • Ensure parity across FFS and MCOs and transparency regarding hepatitis C coverage criteria.
Hawaii

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

Hawaii Medicaid FFS does not impose liver damage restrictions. Most Managed Care Organizations (MCOs), including Hawaii Medical Service Association, Ohana Health Plan, and UnitedHealthcare Community Plan, also do not impose liver damage restrictions. AlohaCare and Kaiser Permanente do not have publicly available hepatitis c coverage criteria.

Sobriety restrictions

Hawaii Medicaid FFS requires that providers evaluate alcohol use and urine toxicology results prior to treatment for adherence considerations. Hawaii Medical Service Association, and UnitedHealthcare Community plan impose similar screening requirements. Ohana Health Plan requires patients to be abstinent from alcohol or substance use and requires a negative toxicology screen within the past 100 days prior to initiation of treatment. AlohaCare and Kaiser Permanente do not have publicly available hepatitis c coverage criteria.

Prescriber restrictions

Hawaii Medicaid FFS requires that a prescription be written by or in consultation with a specialist. Hawaii Medical Service Association and Ohana Health Plan also require a specialist to prescribe or consult. UnitedHealthcare Community Plan appears to require a specialist prescription. AlohaCare and Kaiser Permanente do not have publicly available hepatitis c coverage criteria.

Recommendations

  • Remove sobriety and prescriber requirements.
  • Ensure parity across the Medicaid program and ensure transparency so coverage criteria for FFS and MCO plans are publicly accessible.
Idaho

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Idaho does not impose liver damage restrictions.

Sobriety restrictions

Idaho requires that providers consider substance use disorders in adherence counseling, and the prior authorization form directs providers to “[p]lease consider follow up or referral for Medication-assisted treatment (MAT) in patients with opioid use disorder.

Prescriber restrictions

Idaho does not impose prescriber restrictions.

Recommendations

  • Remove sobriety restrictions.
  • Maintain transparency regarding hepatitis C coverage criteria.
Illinois

State of Hepatitis C Medicaid Access:

B-

Liver damage restrictions

Fee-For-Service (FFS) does not impose liver damage requirements. Two Managed Care Organizations (MCOs), BlueCross Community Health Plan and Illinicare, also do not impose liver damage requirements. One MCO, Molina, requires severe liver damage (F3 or greater). Three MCOs, Meridian Health Plan, CountyCare Health Plan, and NextLevelHealth, do not provide hepatitis C coverage information publicly.

Sobriety restrictions

FFS requires screening for active substance use. One MCO, BlueCross Community Health Plan, also requires screening. Two MCOs, Illinicare and Molina require six months of sobriety. Three MCOs, Meridian Health Plan, CountyCare Health Plan, and NextLevelHealth, do not provide hepatitis C coverage information publicly.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. One MCOs, BlueCross Community Health Plan also requires a specialist to prescribe or consult. One MCO, Illinicare, requires a specialist to prescribe. One MCO, Molina, does not appear to impose prescriber requirements. Three MCOs, Meridian Health Plan, CountyCare Health Plan, and NextLevelHealth, do not provide hepatitis C coverage information publicly.

Recommendations

  • Eliminate sobriety and prescriber restrictions.
  • Ensure parity across FFS and MCOs and transparency regarding hepatitis C coverage requirements for MCOs.
Indiana

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Indiana does not impose liver damage restrictions.

Sobriety restrictions

Indiana does not impose no sobriety restrictions.

Prescriber restrictions

Indiana requires a prescription by or in consultation with a specialist.

Recommendations

  • Remove prescriber restrictions.
  • Continue to apply FFS requirements across the Medicaid program and maintain transparency regarding hepatitis C coverage.
Iowa

State of Hepatitis C Medicaid Access:

C

Liver damage restrictions

Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) require moderate liver damage (F2 or greater).

Sobriety restrictions

FFS and all MCOs require at least three months’ sobriety from alcohol and substance use, documented by a urine screen.

Prescriber restrictions

FFS and all MCOs requires a liver, infectious disease or digestive disease specialist to prescribe or consult.

Recommendations

  • Remove liver damage, sobriety and prescriber restrictions.
  • Maintain transparency regarding hepatitis C coverage requirements and parity across FFS and MCO programs.
Kansas

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organization (MCOs) do not require a minimum level of liver damage and only require a diagnosis of chronic hepatitis C.

Sobriety restrictions

FFS and MCOs require that patients do not have a history of illicit intravenous drug use within the past 3 months.

Prescriber restrictions

FFS and MCOs require a prescription to be written by or in consultation with a specialist.

Recommendations

  • Eliminate sobriety and prescribing requirements.
  • Maintain transparency and parity regarding hepatitis C coverage across the Medicaid program.
Kentucky

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

Fee-For-Service (FFS) does not impose minimum liver damage restrictions. One Managed Care Organization (MCO), Anthem BlueCross BlueShield of Kentucky, requires severe liver damage (F3 or greater). One MCO, Passport Health Plan, requires at least moderate liver damage (F2 or greater). One MCO, CareSource, imposes severe (F3) and moderate (F2) liver damage requirements on two medications, but does not impose minimum liver damage restrictions on most prescriptions. One MCO, Aetna, follows FFS and does not impose any minimum liver damage restrictions. One MCO, WellCare, has unclear liver damage criteria.

Sobriety restrictions

FFS inquires about patients’ past history of substance use, but does not impose mandated periods of abstinence for individuals seeking first-time treatment. One MCO, Anthem, does not list any sobriety requirements. Three MCOs, Aetna, Passport, and WellCare, require screening for current abuse and counseling as to the risks of substance use during treatment. One MCO, CareSource, requires that members are not currently participating in alcohol abuse or illicit substance abuse, evidenced by one confirmed negative urine drug and alcohol screen within the last 60 days; for previous abusers, it requires confirmation of current monthly negative urine drug and alcohol screen for 3 consecutive months.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. Three MCOs, Aetna Better Health, CareSource-Humana and WellCare, require a specialist to prescribe. One MCO, Passport Health Plan, requires a prescription to be written by or in consultation with a specialist. One MCO, Anthem BlueCross BlueShield, does not specify prescriber requirements.

Recommendations

  • Eliminate prescriber requirements.
  • Ensure and parity across FFS and MCO programs and transparency regarding hepatitis C coverage criteria.
Louisiana

State of Hepatitis C Medicaid Access:

A

Liver damage restrictions

Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) do not impose liver damage restrictions.

Sobriety restrictions

FFS and all MCOs do not impose sobriety restrictions.

Prescriber restrictions

FFS and all MCOs do not impose prescriber restrictions.

Recommendations

  • Continue to provide access to hepatitis C medications for all Medicaid beneficiaries.
  • Maintain transparency regarding hepatitis C coverage requirements.
Maine

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Maine requests a patient’s liver damage but does not stipulate any requirements.

Sobriety restrictions

Maine does not impose sobriety restrictions.

Prescriber restrictions

Maine requires a prescription be written by or in consultation with a prescriber.

Recommendations

  • Remove prescriber requirements.
  • Maintain transparency regarding hepatitis C coverage criteria.
Maryland

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

Fee-For-Service (FFS) requires at least minor liver damage (F1 or greater). Seven Managed Care Organizations (MCOs), Aetna, Amerigroup Community Care, Jai Medical Systems, Maryland Physicians Care, MedStar Family Choice, UnitedHealthcare Community Plan, and University of Maryland Health Partners, also require at least minor liver damage (F1 or greater). Two MCOs, Kaiser Permanente and Priority Partners, have unclear liver damage criteria.

Sobriety restrictions

FFS and all MCOs require screening for active alcohol and substance use.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist or provider with expertise in hepatitis c management. Seven MCOs, Aetna, Amerigroup Community Care, Jai Medical Systems, Maryland Physicians Care, MedStar Family Choice, UnitedHealthcare Community Plan, and University of Maryland Health Partners, also require a prescription to be written by or in consultation with a specialist or provider with expertise in hepatitis c management. Two MCOs, Kaiser Permanente and Priority Partners, have unclear prescriber requirements.

Recommendations

  • Eliminate liver damage, sobriety and prescribing requirements.
  • Ensure hepatitis C coverage transparency by all MCOs.
Massachusetts

State of Hepatitis C Medicaid Access:

A

Liver damage restrictions

Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) do not have any liver damage restrictions.

Sobriety restrictions

FFS and MCOs do not have any sobriety restrictions.

Prescriber restrictions

FFS and MCOs do not have any prescriber restrictions.

Recommendations

  • Maintain open access and transparency regarding hepatitis C coverage requirements.
Michigan

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Michigan does not impose liver damage restrictions.

Sobriety restrictions

FFS and MCOs require documentation of use of illegal drugs or abuse of alcohol within the past six months, however this information is considered for the sole purpose of optimizing treatment.

Prescriber restrictions

FFS and MCOs require a prescription be written by or in consultation with a specialist.

Recommendations

  • Eliminate liver damage, sobriety and prescriber restrictions.
  • Maintain transparency regarding coverage criteria and parity across the Medicaid program.
Minnesota

State of Hepatitis C Medicaid Access:

D+

Liver damage restrictions

Fee-For-Service (FFS) liver damage requirements differ for preferred versus non-preferred hepatitis C medications. Beneficiaries prescribed a preferred agent could qualify for treatment with no liver damage (F0). Patients needing a non-preferred regimen must have severe liver damage (F3 or greater). Three MCOs, Blue Plus, South Country Health Alliance and UCare, have the same requirements as FFS. One MCO, HealthPartners, has no liver damage requirements. Two MCOs, Itasca Medical Care and PrimeWest Health, have unclear liver damage requirements. One MCO, Hennepin Health, does not provide hepatitis C coverage criteria publicly.

Sobriety restrictions

FFS requires six months abstinence from alcohol and substance use. Beneficiaries who meet certain criteria could qualify for treatment after three months sobriety. Three MCOs, Blue Plus, South Country Health Alliance and UCare, have the same sobriety requirements as FFS. One MCO, HealthPartners, requires documentation of the individual’s alcohol and drug use history. The beneficiary must agree to abstinence during the course of treatment and be subject to random alcohol and drug screening. One MCO, Itasca Medical Care, requires abstinence during and after treatment with the beneficiary committing to random drug screening. One MCO, PrimeWest Health, has unclear sobriety requirements. One MCO, Hennepin Health, does not provide hepatitis C coverage criteria publicly.

Prescriber restrictions

FFS requires a prescription by or in consultation with a specialist. Three MCOs, Blue Plus, South Country Health Alliance and UCare, have the same prescriber requirements as FFS. One MCO, PrimeWest Health, requires a specialist or provider who has participated in a hepatitis C training and management collaboration to prescribe. Two MCOs, HealthPartners and Itasca Medical Care, have unclear prescriber requirements. One MCO, Hennepin Health, does not provide hepatitis C coverage criteria publicly.

Recommendations

  • Eliminate liver damage, sobriety and prescribing requirements.
  • Ensure parity across FFS and MCOs and transparency regarding hepatitis C coverage criteria.
Mississippi

State of Hepatitis C Medicaid Access:

D+

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not specify liver damage requirements.

Sobriety restrictions

FFS and MCOs require 6 months abstinence documented by a urine screen for beneficiaries with a history of use.

Prescriber restrictions

FFS and MCOs require a prescription by or in consultation with a specialist.

Recommendations

  • Remove sobriety and prescriber restrictions.
  • Maintain hepatitis C coverage parity across the FFS and MCO program and transparency regarding coverage criteria.
Missouri

State of Hepatitis C Medicaid Access:

A

Liver damage restrictions

Missouri does not impose any liver damage restrictions.

Sobriety restrictions

Missouri does not impose a specific abstinence period but does require prescribers to address “ongoing misuse of alcohol or illicit IV substances (if appropriate).”

Prescriber restrictions

Missouri does not impose prescriber restrictions.

Recommendations

  • Preserve open access to hepatitis C medications.
  • Maintain parity across Fee-For-Service (FFS) and Managed Care Organizations (MCOs) and transparency regarding hepatitis C coverage.
Montana

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Montana does not impose liver damage restrictions.

Sobriety restrictions

Montana requires screening and counseling for drug and alcohol use.

Prescriber restrictions

Montana does not impose prescriber restrictions.

Recommendations

  • Remove drug and alcohol use screening requirement.
  • Maintain transparency regarding hepatitis C coverage criteria.
Nebraska

State of Hepatitis C Medicaid Access:

C-

Liver damage restrictions

Fee-For Service requires moderate liver damage (F2 or greater). Two Managed Care Organizations (MCOs), Nebraska Total Care and WellCare of Nebraska, also require moderate liver damage (F2 or greater). One MCO, UnitedHealthcare Community Plan, requires severe liver damage (F3 or greater).

Sobriety restrictions

FFS and all MCOs require six months of abstinence or evidence of participation in a treatment program.

Prescriber restrictions

FFS does not impose prescriber restrictions. Two MCOs, Nebraska Total Care WellCare of Nebraska also do not impose prescriber restrictions. One MCO, UnitedHealthcare Community Plan, requires a specialist to prescribe.

Recommendations

  • Remove liver damage and sobriety restrictions.
  • Ensure coverage parity across FFS and MCO programs.
Nevada

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Fee-For-Service (FFS) and Primary Care Case Management (PCCM) do not have liver damage requirements. One Managed Care Organization (MCO), Amerigroup, complies with Nevada Division of Health Care Financing and Policy’s mandate to follow FFS criteria and does not have liver damage requirements. Two MCOs, Health Plan of Nevada and SilverSummit Healthplan, do not provide hepatitis C coverage criteria publicly.

Sobriety restrictions

FFS/PCCM do not impose sobriety restrictions. One MCO, Amerigroup, complies with Nevada Division of Health Care Financing and Policy’s mandate to follow FFS criteria and does not impose sobriety restrictions. Two MCOs, Health Plan of Nevada and SilverSummit Healthplan, do not provide hepatitis C coverage criteria publicly.

Prescriber restrictions

FFS/PCCM do not impose prescribing requirements. One MCO, Amerigroup, complies with Nevada Division of Health Care Financing and Policy’s mandate to follow FFS criteria and does not impose prescribing restrictions. Two MCOs, Health Plan of Nevada and SilverSummit Healthplan, do not provide hepatitis C coverage criteria publicly.

Recommendations

  • Maintain open access to hepatitis C medications and mandated coverage parity across the FFS and MCO programs.
  • Require all MCOs to make their hepatitis C coverage criteria publicly available.
New Hampshire

State of Hepatitis C Medicaid Access:

B+

Liver damage restrictions

New Hampshire does not have liver damage restrictions.

Sobriety restrictions

New Hampshire requires the prescriber to screen and counsel beneficiaries and administer ongoing testing throughout treatment to ensure abstinence.

Prescriber restrictions

New Hampshire requires a prescription by or in consultation with a specialist or by a prescriber who has completed continuing medical education on the treatment of hepatitis C.

Recommendations

  • Remove sobriety and prescriber restrictions.
  • Maintain parity across Fee-For-Service (FFS) and Managed Care Organizations(MCOs) and transparency regarding hepatitis C coverage criteria.
New Jersey

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) do not impose liver damage requirements.

Sobriety restrictions

FFS and all MCOs do not impose sobriety requirements.

Prescriber restrictions

FFS and four MCOs, Aetna, Horizon, UHC, and Wellcare, require a specialist to prescribe. One MCO, Amerigroup, does not impose prescriber restrictions.

Recommendations

  • Eliminate liver damage, sobriety and prescriber requirements.
  • Achieve hepatitis C coverage parity across FFS and MCO programs and provide transparency regarding hepatitis C coverage criteria.
New Mexico

State of Hepatitis C Medicaid Access:

A

Liver damage restrictions

Fee-For-Service (FFS) does not impose any liver damage restrictions. New Mexico’s Medical Assistance Division (MAD) requires all Managed Care Organizations (MCOs) to follow FFS criteria. Two MCOs (Molina Healthcare and UnitedHealthcare (UHC)) are complying. One MCO (Presbyterian) is not complying and requires at least minimal liver damage (F1 or greater). Coverage requirements for one MCO (BlueCrossBlueShield (BCBS)) are not publicly available.

Sobriety restrictions

FFS requires patients with a history of alcohol or substance use to be referred for counseling and substance use treatment, but does not deny coverage based on such history. New Mexico also prohibited MCOs from issuing approvals or denials based on active alcohol or substance use screening. Three MCOs (Molina, Presbyterian and UHC) are complying and do not impose sobriety requirements. Coverage requirements for one MCO (BCBS) are not publicly available.

Prescriber restrictions

FFS does not impose prescriber requirements. Three MCOs (Molina, Presbyterian, and UHC) have complied and do not impose prescriber requirements. Coverage requirements for one MCO (BCBS) are not publicly available.

Recommendations

  • Ensure all MCOs comply with New Mexico’s MAD’s directive regarding hepatitis C coverage requirements.
  • Require transparency regarding hepatitis C coverage criteria.
New York

State of Hepatitis C Medicaid Access:

A-

Liver damage (Fibrosis) restrictions

Fee-For-Service (FFS) does not impose liver damage restrictions. Most MCOs, including AmidaCare, BlueCross BlueShield, Capital District Physicians Health Plan, Empire, Excellus, Fidelis Care, UnitedHealthcare, Univera Healthcare, VNSNY, Wellcare, and YourCare Health Plan, follow the FFS criteria. Eight MCOs, Affinity Health Plan, Crystal Run Health Plans, EmblemHealth, HealthFirst, Independent Health, MetroPlus Health Plan, MVP Health Care, and Molina Healthcare, do not provide hepatitis c coverage information publicly.

Sobriety restrictions

FFS requires screening for substance and alcohol use and assurance for treatment readiness. Five MCOs, Excellus, UnitedHealthcare, Univera Healthcare, VNSNY, and Your Care Health Plan follow the FFS criteria. Five MCOs, AmidaCare, BlueCross BlueShield, Capital District Physicians Health Plan, Empire, and Fidelis Care, do not impose sobriety restrictions. One MCO, Wellcare, requires a urine toxicology screen within the past 30 days prior to submitting treatment authorization. Eight MCOs, Affinity Health Plan, Crystal Run Health Plans, EmblemHealth, HealthFirst, Independent Health, MetroPlus Health Plan, MVP Health Care, and Molina Healthcare, do not provide hepatitis c coverage information publicly.

Prescriber restrictions

FFS does not impose prescriber restrictions. Seven MCOs, AmidaCare, BlueCross BlueShield, Capital District Physicians Health Plan, Empire, Excellus, Univera Healthcare, and Wellcare follow the FFS criteria. One MCO, YourCare Health Plan, requires a specialist to prescribe or consult. Two MCOs, Fidelis Care and UnitedHealthcare, asks for the specialty of the prescriber but has unclear requirements. One MCO, VNSNY, requires a specialist to prescribe. Eight MCOs, Affinity Health Plan, Crystal Run Health Plans, EmblemHealth, HealthFirst, Independent Health, MetroPlus Health Plan, MVP Health Care, and Molina Healthcare, do not provide hepatitis c coverage information publicly.

Recommendations

  • Remove requirement that provider screen for active substance use.
  • Ensure coverage parity across the FFS and MCO programs and transparency regarding hepatitis C coverage criteria.
North Carolina

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

North Carolina does not impose any liver damage restrictions.

Sobriety restrictions

Fee-For-Service (FFS) and Primary Care Case Management System (PCCM) require screening and counseling for alcohol and substance use. Patients with a history of substance use in the last year must be enrolled in a treatment program and agree to abstinence during treatment as well as toxicology screening.

Prescriber restrictions

FFS and PCCM appear not to impose prescriber requirements.

Recommendations

  • Remove sobriety restrictions.
  • Maintain transparency regarding hepatitis C coverage requirements.
North Dakota

State of Hepatitis C Medicaid Access:

C+

Liver damage restrictions

Fee-For-Service (FFS) and Primary Care Case Management (PCCM) do not impose liver damage restrictions. The Managed Care Organization (MCO), Sanford Health Plan, does not have publicly available hepatitis C coverage criteria.

Sobriety restrictions

FFS/PCCM require three months of abstinence from alcohol and injection drug use. The MCO, Sanford Health Plan, does not have publicly available hepatitis C coverage criteria.

Prescriber restrictions

FFS/PCCM require a prescription to be written by or in consultation with a specialist. The MCO, Sanford Health Plan, does not have publicly available hepatitis C coverage criteria.

Recommendations

  • Remove sobriety and prescriber requirements.
  • Ensure parity across FFS and MCO and transparency regarding hepatitis C coverage requirements.
Ohio

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Ohio does not impose liver damage restrictions.

Sobriety restrictions

Ohio does not impose sobriety restrictions.

Prescriber restrictions

Ohio requires a prescription written by or in consultation with a gastroenterologist, hepatologist, or infectious disease physician.

Recommendations

  • Eliminate prescriber restrictions and allow primary care and other providers to prescribe hepatitis C treatment.
Oklahoma

State of Hepatitis C Medicaid Access:

C

Liver damage restrictions

Oklahoma imposes no liver damage requirements (F0 or greater) for preferred treatments (Epclusa, and Mavyret). Non-preferred regimens (Daklinza, Harvoni, Olysio, Sovaldi, Technivie, and Viekira PAK/XR) require moderate liver damage (F2 or greater). Additionally, many clinical issues including, but not limited to anemia, surgery, depression, obesity, epilepsy, psychosis, weight management, or severe concurrent medical diseases must be addressed before starting therapy.

Sobriety restrictions

Oklahoma requires screening and counseling for alcohol and substance use as well as the beneficiary to commit to abstain from alcohol and substance use during and after treatment. Patients must agree to random drug testing during treatment.

Prescriber restrictions

Oklahoma requires a prescription be written by or in consultation with a gastroenterologist, infectious disease, or transplant specialist.

Recommendations

  • Completely remove liver damage, sobriety and prescriber requirements.
  • Maintain transparency regarding hepatitis C coverage requirements.
Oregon

State of Hepatitis C Medicaid Access:

A-

Liver damage (Fibrosis) restrictions

Ohio does not impose liver damage restrictions.

Sobriety restrictions

Ohio does not impose sobriety restrictions.

Prescriber restrictions

Ohio requires a prescription written by or in consultation with a gastroenterologist, hepatologist, or infectious disease physician.

Recommendations

  • Eliminate prescriber restrictions and allow primary care and other providers to prescribe hepatitis C treatment.
Pennsylvania

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Effective January 1, 2018, Fee-For-Service (FFS) eliminated its liver damage requirements: beneficiaries with no liver damage (F0 or greater) can qualify for treatment. Aetna Better Health, AmeriHealth Caritas Pennsylvania, Geisinger Health Plan, Keystone First Health Plan, Health Partners, UPMC for You and UnitedHealthcare Community Plan do not list minimum liver damage requirements. Gateway Health Plan still has a publicly available eligibility document clearly indicating that at least minor liver damage (F1 or greater) is required.

Sobriety restrictions

FFS and all MCOs require the prescriber to screen and counsel beneficiaries on alcohol and substance use as well as offer a referral for substance use treatment.

Prescriber restrictions

FFS does not impose prescriber restrictions. Five MCOs, Aetna, AmeriHealth, Gateway, Health Partners, and Keystone also do not impose prescriber restrictions. Three MCOs, Geisinger, UPMC, and UnitedHealtcare Community Plan, require a prescription from a specialist.

Recommendations

• Eliminate the requirement to screen beneficiaries for substance use.
• Ensure all MCOs comply with the hepatitis C coverage mandate to create equal access to medications across the Medicaid program and transparency regarding hepatitis C coverage criteria.
• Ensure transparency of requirements by MCOs.

Puerto Rico

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

Puerto Rico does not have any liver damage restrictions.

Sobriety restrictions

Puerto Rico requires screening and counseling for alcohol and substance use.

Prescriber restrictions

Puerto Rico requires a specialist to prescribe.

Recommendations

  • Remove the requirements that patients are asked about substance use.
  • Allow primary care physicians to prescribe hepatitis c treatment.
Rhode Island

State of Hepatitis C Medicaid Access:

A-

Liver damage restrictions

Fee-For-Service (FFS) does not impose liver damage restrictions. One Managed Care Organization (MCO), Neighborhood Health Plan, requires severe liver damage (F3 or greater). One MCO, UnitedHealthcare Community Plan, does not impose liver damage restrictions. One MCO, Tufts Health Plan, does not have publicly available treatment criteria.

Sobriety restrictions

FFS does not impose sobriety restrictions. Two MCOs, UnitedHealthcare Community Plan and Neighborhood Health Plan, do not impose sobriety restrictions. One MCO, Tufts Health Plan, does not have publicly available treatment criteria.

Prescriber restrictions

FFS requires that for patients with severe liver damage (F3 or F4), the provider must be on the Rhode Island Medicaid Hepatitis C Preferred Provider List, or such provider must be consulted and co-manage the patients with a primary care provider. All other patients can be treated by a primary care physician, advance practice nurse, or physician assistant. Two MCOs, UnitedHealthcare Community Plan and Neighborhood Health Plan, require the prescriber to be approved by the state. One MCO, Tufts Health Plan, does not have publicly available treatment criteria.

Recommendations

  • Remove liver damage, sobriety and prescriber requirements.
  • Ensure hepatitis C coverage parity across FFS and MCO programs and transparency regarding hepatitis C coverage guidelines.
South Carolina

State of Hepatitis C Medicaid Access:

B+

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have any liver damage requirements.

Sobriety restrictions

FFS and MCOs require screening and counseling for alcohol and substance use.

Prescriber restrictions

FFS and MCOs require a prescription to be written by or in consultation with a specialist.

Recommendations

  • Eliminate sobriety and prescriber restrictions.
  • Maintain parity across FFS and MCOs and transparency regarding hepatitis C coverage criteria.
South Dakota

State of Hepatitis C Medicaid Access:

F

Liver damage restrictions

South Dakota requires severe liver damage (F3 or greater) to qualify for treatment.

Sobriety restrictions

South Dakota requires six months of abstinence from alcohol and substance use.

Prescriber restrictions

South Dakota requires a specialist to prescribe treatment or consult with the prescribing provider.

Recommendations

  • Remove liver damage, sobriety and prescriber requirements.
  • Maintain transparency regarding hepatitis C coverage requirements.
Tennessee

State of Hepatitis C Medicaid Access:

C

Liver damage restrictions

Tennessee Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not impose liver damage restrictions.

Sobriety restrictions

Tennessee FFS and MCOs require six months of sobriety for beneficiaries with a history of alcohol or substance use.

Prescriber restrictions

Tennessee FFS and MCOs allow all physicians to prescribe treatment except in certain clinical situations in which a specialist must consult.

Recommendations

  • Remove sobriety and prescriber restrictions.
  • Maintain parity across FFS and MCO programs and transparency regarding hepatitis C coverage requirements.
Texas

State of Hepatitis C Medicaid Access:

D+

Liver damage restrictions

Fee-For-Service (FFS) requires severe liver damage (F3 or greater). Thirteen of 15 Managed Care Organizations (MCOs) impose the same liver damage requirements as FFS: Aetna, Amerigroup, BlueCross BlueShield, Cigna HealthSpring, Christus Health Plan, Community Health First Plans, El Paso First Health, FirstCare STAR Health Plans, Molina Healthcare, Scott & White, Sendero Health Plans, Superior HealthPlan and UnitedHealthcare. Community Health Choice and Parkland Community Health do not provide hepatitis C coverage criteria publicly.

Sobriety restrictions

FFS requires screening for substance use within 90 days prior to submitting a prior authorization request. Thirteen of 15 MCOs impose the same sobriety criteria as the FFS program: Aetna, Amerigroup, BlueCross BlueShield, Cigna HealthSpring, Christus Health Plan, Community Health First Plans, El Paso First Health, FirstCare STAR Health Plans, Molina Healthcare, Scott & White, Sendero Health Plans, Superior HealthPlan and UnitedHealthcare. Community Health Choice and Parkland Community Health do not provide hepatitis C coverage criteria publicly.

Prescriber restrictions

FFS requires a prescription be written by or in consultation with a specialist. Thirteen of 15 MCOs impose the same prescribing requirements as FFS: Aetna, Amerigroup, BlueCross BlueShield, Cigna HealthSpring, Christus Health Plan, Community Health First Plans, El Paso First Health, FirstCare STAR Health Plans, Molina Healthcare, Scott & White, Sendero Health Plans, Superior HealthPlan and UnitedHealthcare. Community Health Choice and Parkland Community Health do not provide hepatitis C coverage criteria publicly.

Recommendations

  • Remove liver damage, sobriety and prescriber restrictions.
  • Maintain coverage parity across the FFS and MCO programs and ensure transparency regarding hepatitis C coverage in all MCOsRequire continued parity between the Fee-For-Service (FFS) and Managed Care (MCO) programs ensuring all Medicaid beneficiaries can access treatment.
Utah

State of Hepatitis C Medicaid Access:

C-

Liver damage restrictions

Fee-For-Service (FFS) does not impose liver damage requirements. One Managed Care Organization (MCO), Health Choice Utah, does not impose liver damage requirements. One MCO (SelectHealth) allows patients with no liver damage to request treatment, but beneficiaries must demonstrate six months of sobriety. One MCO (Molina Healthcare of Utah) requires severe liver damage (F3 or greater). One MCO (Healthy U) does not have publicly available hepatitis C coverage criteria.

Sobriety restrictions

FFS does not impose sobriety restrictions. One MCO (Health Choice) requires beneficiaries with a history of alcohol or substance use to be abstinent for three months and enrolled in a substance use treatment program. One MCO (Molina Healthcare) requires six months of abstinence from alcohol or drug use before submitting a prior authorization (PA) request. One MCO (SelectHealth) requires demonstration of six months of sobriety for beneficiaries with no or minimal liver damage. One MCO (Healthy U) does not have publicly available hepatitis C coverage criteria.

Prescriber restrictions

FFS requires a prescription be written by or in consultation with a specialist. One MCO (Health Choice) also requires a prescription by or in consultation with a specialist. One MCO (SelectHealth) requires a specialist to prescribe. One MCO (Molina Healthcare) does not list prescribing requirements. One MCO (Healthy U) does not have publicly available hepatitis C coverage criteria.

Recommendations

  • Require coverage parity between FFS and MCOs.
  • Ensure transparency regarding hepatitis C coverage requirements.
  • Vermont

    State of Hepatitis C Medicaid Access:

    A-

    Liver damage restrictions

    Vermont does not impose any liver damage restrictions.

    Sobriety restrictions

    Vermont does not have any sobriety restrictions.

    Prescriber restrictions

    Vermont requires a prescription by or in consultation with a specialist.

    Recommendations

    • Remove prescriber restrictions.
    • Maintain transparency regarding hepatitis C coverage criteria.
    Virginia

    State of Hepatitis C Medicaid Access:

    B+

    Liver damage restrictions

    Fee-For Service (FFS) and Managed Care Organizations (MCOs) do not have liver damage restrictions.

    Sobriety restrictions

    FFS and MCOs require beneficiaries to be evaluated for current substance or alcohol use. Those identified with alcohol or substance use should be referred for treatment. Prior authorization (PA) forms state explicitly that a patient can’t be denied treatment for the sole reason of substance use.

    Prescriber restrictions

    FFS and MCOs require a prescription be written by or in consultation with a specialist.

    Recommendations

    • Eliminate sobriety and prescriber requirements.
    • Require continued parity between FFS and MCOs and maintain transparency regarding hepatitis C coverage criteria.
    Washington

    State of Hepatitis C Medicaid Access:

    A

    Liver damage restrictions

    Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have any liver damage restrictions.

    Sobriety restrictions

    FFS and MCOs do not have any sobriety restrictions.

    Prescriber restrictions

    FFS and MCOs do not impose prescriber restrictions.

    Recommendations

    • Continue to provide access to hepatitis C treatment to all beneficiaries.
    • Maintain coverage parity across the Medicaid program and transparency regarding coverage requirements.
    West Virginia

    State of Hepatitis C Medicaid Access:

    B-

    Liver damage restrictions

    West Virginia does not impose liver damage restrictions.

    Sobriety restrictions

    FFS and MCOs require three months abstinence from alcohol and substance use.

    Prescriber restrictions

    FFS and MCOs require a prescription to be written by or in conjunction with a specialist.

    Recommendations

    • Remove liver damage, sobriety and prescriber restrictions.
    • Maintain the “carve out” of hepatitis C medications from MCO contracts and continue applying FFS coverage requirements across the Medicaid program.
    Wisconsin

    State of Hepatitis C Medicaid Access:

    A

    Liver damage restrictions

    Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have any liver damage restrictions.

    Sobriety restrictions

    FFS and MCOs do not have any sobriety restrictions.

    Prescriber restrictions

    FFS and MCOs do not have any prescriber restrictions.

    Recommendations

    • Continue to provide access to hepatitis C treatment to all beneficiaries.
    • Maintain coverage parity between FFS and MCOs.
    Wyoming

    State of Hepatitis C Medicaid Access:

    B

    Liver damage restrictions

    Wyoming does not have any liver damage restrictions.

    Sobriety restrictions

    Wyoming requires abstinence from drugs and alcohol for one month.

    Prescriber restrictions

    Wyoming does not have any prescriber restrictions.

    Recommendations

    • Remove sobriety restriction.
    • Maintain transparency regarding hepatitis C coverage criteria.