State of Hepatitis C Medicaid Access:
Alabama requires at least moderate liver damage (F2 or greater).
Alabama requires abstinence from drugs and alcohol for at least six months.
Alabama does not appear to impose any prescriber restrictions.
State of Hepatitis C Medicaid Access:
Alaska Medicaid does not any liver damage requirements.
Alaska Medicaid requires screening and a referral to treatment for active alcohol or illicit substance use.
Alaska Medicaid has no prescriber restrictions except for when a patient has specific clinic criteria.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Arkansas requires severe liver damage (F3 or greater), depending on a patient’s genotype and whether the individual is treatment naïve or experienced.
Arkansas requires abstinence from drugs and alcohol for at least six months.
Arkansas requires a specialist, or a provider working under direct supervision of a specialist, to prescribe.
State of Hepatitis C Medicaid Access:
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.
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.
FFS and MCOs do not have prescriber requirements.
State of Hepatitis C Medicaid Access:
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.
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.
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.
• 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.
State of Hepatitis C Medicaid Access:
Connecticut does not impose any liver damage restrictions.
Connecticut does not impose any sobriety restrictions.
Connecticut does not impose any prescriber restrictions.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
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.
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.
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.
• Remove sobriety and prescriber restrictions.
• Require coverage parity across the FFS and MCO program and ensure transparency regarding coverage criteria for hepatitis C medications.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require a diagnosis of hepatitis C. Neither imposes liver damage requirements.
FFS and MCOs require one-month sobriety prior to initiating treatment.
FFS and MCOs require a prescription be written by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Idaho does not impose liver damage 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.
Idaho does not impose prescriber restrictions.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Indiana does not impose liver damage restrictions.
Indiana does not impose no sobriety restrictions.
Indiana requires a prescription by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
Iowa does not impose liver damage restrictions.
FFS and all MCOs require at least three months’ sobriety from alcohol and substance use, documented by a urine screen.
FFS and all MCOs requires a liver, infectious disease or digestive disease specialist to prescribe or consult.
State of Hepatitis C Medicaid Access:
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.
FFS and MCOs require that patients do not have a history of illicit intravenous drug use within the past 3 months.
FFS and MCOs require a prescription to be written by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) do not impose liver damage restrictions.
FFS and all MCOs do not impose sobriety restrictions.
FFS and all MCOs do not impose prescriber restrictions.
State of Hepatitis C Medicaid Access:
Maine requests a patient’s liver damage but does not stipulate any requirements.
Maine does not impose sobriety restrictions.
Maine requires a prescription be written by or in consultation with a prescriber.
State of Hepatitis C Medicaid Access:
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.
FFS and all MCOs require screening for active alcohol and substance use.
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.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) do not have any liver damage restrictions.
FFS and MCOs do not have any sobriety restrictions.
FFS and MCOs do not have any prescriber restrictions.
State of Hepatitis C Medicaid Access:
Michigan does not impose liver damage 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.
FFS and MCOs require a prescription be written by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not specify liver damage requirements.
FFS and MCOs require 6 months abstinence documented by a urine screen for beneficiaries with a history of use.
FFS and MCOs require a prescription by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
Missouri does not impose any liver damage 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).”
Missouri does not impose prescriber restrictions.
State of Hepatitis C Medicaid Access:
Montana does not impose liver damage restrictions.
Montana requires screening and counseling for drug and alcohol use.
Montana does not impose prescriber restrictions.
State of Hepatitis C Medicaid Access:
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).
FFS and all MCOs require six months of abstinence or evidence of participation in a treatment program.
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.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
New Hampshire does not have liver damage restrictions.
New Hampshire requires the prescriber to screen and counsel beneficiaries and administer ongoing testing throughout treatment to ensure abstinence.
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.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and all Managed Care Organizations (MCOs) do not impose liver damage requirements.
FFS and all MCOs do not impose sobriety requirements.
FFS and four MCOs, Aetna, Horizon, UHC, and Wellcare, require a specialist to prescribe. One MCO, Amerigroup, does not impose prescriber restrictions.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
North Carolina does not impose any liver damage 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.
FFS and PCCM appear not to impose prescriber requirements.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Ohio does not impose liver damage restrictions.
Ohio does not impose sobriety restrictions.
Ohio requires a prescription written by or in consultation with a gastroenterologist, hepatologist, or infectious disease physician.
State of Hepatitis C Medicaid Access:
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.
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.
Oklahoma requires a prescription be written by or in consultation with a gastroenterologist, infectious disease, or transplant specialist.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and most MCOs do not impose liver damage restrictions. Advanced Health, AllCare CCO, Columbia Pacific CCO, Health Share, InterCommunity Health Network CCO, Jackson Care Connect, PacificSource Community Solutions CCO, Trillium Community Health Plan, and Umpqua Health Alliance follow the FFS criteria. Cascade Health Alliance, Eastern Oregon CCO, PrimaryHealth, and Yamhill Community Care do not provide hepatitis C coverage requirements publicly.
FFS and most MCOs do not impose sobriety restrictions. Advanced Health, AllCare CCO, Columbia Pacific CCO, Health Share, InterCommunity Health Network CCO, Jackson Care Connect, PacificSource Community Solutions CCO, Trillium Community Health Plan, and Umpqua Health Alliance follows the FFS criteria. Cascade Health Alliance, Eastern Oregon CCO, PrimaryHealth, and Yamhill Community Care do not provide hepatitis C coverage requirements publicly.
FFS does not impose prescriber restrictions except for patients with cirrhosis (F4), for which a specialist must be consulted. Advanced Health, AllCare CCO, Columbia Pacific CCO, Health Share, PacificSource Community Solutions CCO, Trillium Community Health Plan, and Umpqua Health Alliance follows the FFS criteria. InterCommunity Health Network CCO and Jackson Care Connect require a specialist to consult. Cascade Health Alliance, Eastern Oregon CCO, PrimaryHealth, and Yamhill Community Care do not provide hepatitis C coverage requirements publicly.
State of Hepatitis C Medicaid Access:
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.
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.
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.
• 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.
State of Hepatitis C Medicaid Access:
Puerto Rico does not have any liver damage restrictions.
Puerto Rico requires screening and counseling for alcohol and substance use.
Puerto Rico requires a specialist to prescribe.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have any liver damage requirements.
FFS and MCOs require screening and counseling for alcohol and substance use.
FFS and MCOs require a prescription to be written by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
South Dakota requires severe liver damage (F3 or greater) to qualify for treatment.
South Dakota requires six months of abstinence from alcohol and substance use.
South Dakota requires a specialist to prescribe treatment or consult with the prescribing provider.
State of Hepatitis C Medicaid Access:
Tennessee Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not impose liver damage restrictions.
Tennessee FFS and MCOs require six months of sobriety for beneficiaries with a history of alcohol or substance use.
Tennessee FFS and MCOs allow all physicians to prescribe treatment except in certain clinical situations in which a specialist must consult.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Vermont does not impose any liver damage restrictions.
Vermont does not have any sobriety restrictions.
Vermont requires a prescription by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
Fee-For Service (FFS) and Managed Care Organizations (MCOs) do not have liver damage 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.
FFS and MCOs require a prescription be written by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have any liver damage restrictions.
FFS and MCOs do not have any sobriety restrictions.
FFS and MCOs do not impose prescriber restrictions.
State of Hepatitis C Medicaid Access:
West Virginia does not impose liver damage restrictions.
FFS and MCOs require three months abstinence from alcohol and substance use.
FFS and MCOs require a prescription to be written by or in conjunction with a specialist.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) do not have any liver damage restrictions.
FFS and MCOs do not have any sobriety restrictions.
FFS and MCOs do not have any prescriber restrictions.
State of Hepatitis C Medicaid Access:
Wyoming does not have any liver damage restrictions.
Wyoming requires abstinence from drugs and alcohol for one month.
Wyoming does not have any prescriber restrictions.
