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.
  • Maintain the carve out of pharmacy services from the Regional Care Organization model to ensure all Medicaid beneficiaries can access hepatitis C treatment.

Read full report card

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:

B+

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require at least moderate liver damage (F2 or greater). However, there is a broad range of clinical criteria and high risk of exposure under which a beneficiary can access treatment with less liver damage, including active injection drug use and women of childbearing age who wish to become pregnant, among others.

Sobriety restrictions

FFS and MCOs do not have sobriety requirements.

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:

D+

Liver damage restrictions

Hawaii Medicaid requires that patients with at least minimal liver damage (F1 or greater) qualify to access treatment. It is assumed that Fee-For-Service (FFS) imposes this requirement. Most Managed Care Organization (MCO) plans (Hawaii Medical Service Association, AlohaCare and Ohana Health Plan) have complied, but one plan (UnitedHealthcare Community Plan) requires severe liver damage (F3 or greater). Kaiser Permanente’s coverage criteria are not publicly available.

Sobriety restrictions

Hawaii Medicaid requires that patients be abstinent from alcohol or substance use within the three months prior to treatment documented by blood or urine screen. It is assumed that FFS imposes this requirement. MCO plans’ sobriety requirements vary. UnitedHealthcare Community Plan requires a negative drug screen within 30 days prior to submitting the prior authorization request. Ohana Health Plan requires a negative urine or blood screen for alcohol and substance use within the past 100 days prior to initiating therapy. AlohaCare requires a beneficiary to be abstinent from alcohol and substance use for three months prior to treatment documented by history and urine toxicology screen. Hawaii Medical Service Association requires six months sobriety prior to treatment initiation. Kaiser Permanente’s coverage requirements are not publicly available.

Prescriber restrictions

Hawaii Medicaid requires that a prescription be written by or in consultation with a specialist. It is assumed that FFS imposes this requirement. While most MCO plans (Hawaii Medical Service Association, AlohaCare and Ohana Health Plan) comply with this prescriber requirement, UnitedHealthcare Community Plan appears to require a specialist to prescribe. Kaiser Permanente’s coverage requirements are not publicly available.

Recommendations

  • Remove liver damage, sobriety and prescriber requirements.
  • Ensure MCOs adhere to Hawaii Medicaid’s requirements to achieve 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:

D

Liver damage restrictions

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

Sobriety restrictions

Idaho requires that a patient not have a history of alcohol or substance use within six months prior to treatment.

Prescriber restrictions

Idaho requires that a patient must be under the care of or in collaboration with an experienced hepatitis C practitioner.

Recommendations

  • Remove liver damage, sobriety and prescriber restrictions.
  • Maintain transparency regarding hepatitis C coverage criteria.
Illinois

State of Hepatitis C Medicaid Access:

D-

Liver damage restrictions

Fee-For-Service (FFS) and Primary Care Case Management (PCCM) require at least severe liver damage (F3 or greater). Four Managed Care Organizations (MCOs), Aetna, Harmony Health Plan, Illinicare Health and Molina Healthcare, also require severe liver damage (F3 or greater). One MCO, BlueCross Community Health Plan, appears to have no liver damage requirements. Three MCOs, Cigna, CountyCare Health Plan and Humana, have unclear liver damage requirements. Four MCOs, Community Care Alliance of Illinois, Family Health Network, Meridian Health Plan and NextLevelHealth, do not provide hepatitis C coverage information publicly.

Sobriety restrictions

FFS and PCCM require screening for active substance use. One MCO, Aetna, requires six months sobriety or participation in an alcohol/substance use treatment program. Two MCOs, Illinicare Health and Molina Healthcare, also require six months abstinence. One MCO, Harmony Health Plan, requires a negative urine drug screen within 15 days of initiating treatment. Four MCOs, BlueCross Community Health Plan, Cigna, CountyCare Health Plan and Humana, do not inquire about current or previous alcohol or substance use. Four MCOs, Community Care Alliance of Illinois, Family Health Network, Meridian Health Plan and NextLevelHealth, do not provide hepatitis C coverage information publicly.

Prescriber restrictions

FFS and PCCM require a prescription to be written by or in consultation with a specialist. Three MCOs, Aetna, Cigna and Illinicare Health, require a specialist to prescribe. Two MCOs, BlueCross Community Health Plan and Molina Healthcare, appear to require a specialist to prescribe. Two MCOs, CountyCare Health Plan and Harmony Health Plan, require a prescription by or in consultation with a specialist. One MCO, Humana, has unclear prescriber requirements. Four MCOs, Community Care Alliance of Illinois, Family Health Network, Meridian Health Plan and NextLevelHealth, do not provide hepatitis C coverage information publicly.

Recommendations

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

State of Hepatitis C Medicaid Access:

B

Liver damage restrictions

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

Sobriety restrictions

FFS and MCOs have no sobriety restrictions.

Prescriber restrictions

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

Recommendations

  • Remove liver damage and 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:

D

Liver damage restrictions

Fee-For-Service (FFS) requires severe liver damage (F3 or greater). All Managed Care Organizations (MCOs), Amerigroup Iowa, AmeriHealth Caritas Iowa and UnitedHealthcare Plan of River Valley, also require severe liver damage (F3 or greater).

Sobriety restrictions

FFS requires at least three months sobriety from alcohol and substance use, documented by a urine screen. Additionally, a prescriber must provide counseling regarding alcohol and substance use and education to prevent transmission. All three MCOs, Amerigroup Iowa, AmeriHealth Caritas Iowa, and UnitedHealthcare Plan of River Valley, impose the same restrictions.

Prescriber restrictions

FFS requires a liver, infectious disease or digestive disease specialist to prescribe. All three MCOs, Amerigroup Iowa, AmeriHealth Caritas Iowa, and UnitedHealthcare Plan of River Valley, impose the same restrictions.

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:

D

Liver damage restrictions

Fee-For-Service (FFS) requires severe liver damage (F3 or greater). Two Managed Care Organizations (MCOs), Sunflower Health Plan and UnitedHealthcare, impose the same requirement. One MCO’s (Amerigroup) liver damage requirements range from a diagnosis of chronic hepatitis C to severe liver damage (F3 or greater) depending on the Direct-Acting Antiviral (DAA) regimen requested.

Sobriety restrictions

FFS requires at least six months sobriety to access treatment. Sunflower Health Plan and UnitedHealthcare impose the same requirement. Amerigroup’s sobriety requirements range from unclear to six months sobriety depending on the regimen requested.

Prescriber restrictions

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

Recommendations

  • Eliminate liver damage, sobriety and prescribing requirements.
  • Maintain transparency regarding hepatitis C coverage requirements and ensure parity 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:

C

Liver damage restrictions

Fee-For-Service (FFS) requires severe liver damage (F3 or greater) for beneficiaries infected with hepatitis C (HCV), but imposes no liver damage requirements for beneficiaries coinfected with HCV and HIV. Five Managed Care Organizations (MCOs) – Aetna Better Health, AmeriHealth Caritas Louisiana, Healthy Blue, Louisiana Healthcare Connections, and UnitedHealthcare – maintain the same requirements.

Sobriety restrictions

FFS and the five MCOs require beneficiaries to attest that they have not been “actively participating” in substance and/or alcohol abuse.

Prescriber restrictions

FFS and the five MCOs impose no prescriber restrictions.

Recommendations

  • Remove liver damage, sobriety and prescriber restrictions.
  • Ensure transparency of coverage requirements for all MCOs and achieve parity across FFS and MCO programs.
Maine

State of Hepatitis C Medicaid Access:

D+

Liver damage restrictions

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

Sobriety restrictions

Maine requires six months abstinence from alcohol and drugs.

Prescriber restrictions

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

Recommendations

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

State of Hepatitis C Medicaid Access:

C

Liver damage restrictions

Fee-For-Service (FFS) requires at least moderate liver damage (F2 or greater). Five Managed Care Organizations (MCOs), Amerigroup Community Care, Jai Medical Systems, Maryland Physicians Care, MedStar Family Choice and University of Maryland Health Partners, also require at least moderate liver damage (F2 or greater). One MCO, UnitedHealthcare, requires severe liver damage (F3 or greater). One MCO, Priority Partners, has unclear liver damage criteria One MCO, Kaiser Permanente, does not have publicly available hepatitis C coverage criteria.

Sobriety restrictions

FFS requires screening for active alcohol and substance use. Six MCOs, Amerigroup Community Care, Jai Medical Systems, Maryland Physicians Care, MedStar Family Choice, Priority Partners and University of Maryland Health Partners, also require screening for active substance use. One MCO, UnitedHealthcare, requires 30 days sobriety confirmed by a negative urine screen. One MCO, Kaiser Permanente, does not have publicly available hepatitis C coverage criteria.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. Five MCOs, Amerigroup Community Care, Jai Medical Systems, Maryland Physicians Care, MedStar Family Choice, and University of Maryland Health Partners, require a prescription to be written by or in consultation with a specialist. One MCO, Priority Partners, has unclear prescriber requirements. One MCO, UnitedHealthcare, requires a specialist to prescribe. One MCO, Kaiser Permanente, does not have publicly available hepatitis C coverage criteria.

Recommendations

  • Eliminate liver damage, sobriety and prescribing requirements.
  • Achieve hepatitis C coverage parity across FFS and MCOs and 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:

D+

Liver damage restrictions

Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require at least moderate liver damage (F2 or greater) to access treatment.

Sobriety restrictions

FFS and MCOs require six months abstinence, although consideration will be given if documentation is provided showing a beneficiary is participating in counseling or a program for sobriety.

Prescriber restrictions

FFS and MCOs require a prescription be written by or in consultation with a specialist. FFS requirements apply across the Medicaid program.

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:

F

Liver damage restrictions

Montana requires severe liver damage (F3 or greater).

Sobriety restrictions

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

Prescriber restrictions

Montana requires a prescription be written by or in consultation with a specialist.

Recommendations

  • Remove liver damage, sobriety and prescriber restrictions.
  • Maintain transparency regarding hepatitis C coverage criteria.
Nebraska

State of Hepatitis C Medicaid Access:

D+

Liver damage restrictions

Fee-For Service requires severe liver damage (F3 or greater). Patients who present certain clinical manifestations can qualify for treatment with less liver damage. Two Managed Care Organizations (MCOs), Nebraska Total Care and UnitedHealthcare Community Plan, also require severe liver damage (F3 or greater). One MCO, WellCare of Nebraska, does not have publicly available hepatitis C coverage criteria.

Sobriety restrictions

FFS requires six months abstinence or evidence of participation in a treatment program. All beneficiaries must provide a negative drug urine screen within 15 days before the prior authorization request. Two MCOs, Nebraska Total Care and UnitedHealthcare Community Plan, impose the same sobriety requirements. One MCO, WellCare of Nebraska, does not have publicly available hepatitis C coverage criteria.

Prescriber restrictions

FFS does not impose prescriber restrictions. Two MCOs, Nebraska Total Care and UnitedHealthcare Community Plan, also do not impose prescriber restrictions. One MCO, WellCare of Nebraska, does not have publicly available hepatitis C coverage criteria.

Recommendations

  • Remove liver damage and sobriety restrictions.
  • Maintain coverage parity across FFS and MCO programs and ensure transparency regarding hepatitis C coverage criteria.
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:

C-

Liver damage restrictions

Fee-For-Service (FFS) requires at least moderate liver damage (F2 or greater). Three Managed Care Organizations (MCOs), Aetna Better Health of New Jersey, Amerigroup and Horizon NJ Health, impose the same liver damage criteria. One MCO, UnitedHealthcare Community Plan, requires severe liver damage (F3 or greater). One MCO, WellCare, has unclear liver damage requirements.

Sobriety restrictions

FFS does not impose sobriety requirements. Three MCOs, Aetna Better Health of New Jersey, Amerigroup and Horizon NJ Health, also do not impose sobriety restrictions. Two MCOs. UnitedHealthcare Community Plan and WellCare, require 30 days of abstinence demonstrated by a negative urine screen.

Prescriber restrictions

FFS has unclear prescribing requirements. Four MCOs, Aetna Better Health of New Jersey, Amerigroup, Horizon NJ Health and UnitedHealthcare Community Plan, require a specialist to prescribe. One MCO, WellCare, has unclear prescribing requirements.

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:

B-

Liver damage restrictions

Fee-For-Service (FFS) does not have liver damage requirements. Six Managed Care Organizations (MCOs), Excellus Health Plan, HealthNow New York, New York State Catholic Health Plan, UnitedHealthcare, WellCare and YourCare Health Plan, follow FFS liver damage criteria. Two MCOs, Healthfirst PHSP and MetroPlus Health Plan, specifically reference the American Association for the Study of Liver Disease/Infectious Disease Society of America (AASLD/IDSA) guidelines in their prior authorization (PA) criteria but don’t specify liver damage requirements. Seven MCOs, Affinity Health Plan, Capital District Physicians Health Plan, Health Insurance Plan of Greater New York, HealthPlus LLC, Independent Health Association, MVP Health Plan, and Molina Healthcare, have limited coverage information publicly available and their liver damage requirements are unclear. One MCO, New York-Presbyterian Community Health Plan, does not provide any coverage information publicly.

Sobriety restrictions

FFS requires screening for substance and alcohol use and assurance for treatment readiness. Five MCOs, Excellus Health Plan, HealthNow New York, New York State Catholic Health Plan, UnitedHealthcare and YourCare Health Plan, follow FFS sobriety criteria. One MCO, WellCare, requires a urine toxicology screen 30 days before treatment. Two MCOs, Healthfirst PHSP and MetroPlus Health Plan, specifically reference the AASLD/IDSA guidelines in their PA criteria but don’t specify sobriety requirements. Seven MCOs, Affinity Health Plan, Capital District Physicians Health Plan, Health Insurance Plan of Greater New York, HealthPlus LLC, Independent Health Association, MVP Health Plan, and Molina Healthcare, have limited coverage information publicly available and their requirements are unclear. One MCO, New York-Presbyterian Community Health Plan, does not provide any coverage information publicly.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. Five MCOs, Excellus Health Plan HealthNow New York, New York State Catholic Health Plan, UnitedHealthcare and YourCare Health Plan, follow FFS prescriber criteria. Two MCOs, Healthfirst PHSP and MetroPlus Health Plan, specifically reference the AASLD/IDSA guidelines in their PA criteria but don’t specify prescriber requirements. WellCare does not specify any prescriber requirements. Seven MCOs, Affinity Health Plan, Capital District Physicians Health Plan, Health Insurance Plan of Greater New York, HealthPlus LLC, Independent Health Association, MVP Health Plan, and Molina Healthcare, have limited coverage information publicly available and their requirements are unclear. One MCO, New York-Presbyterian Community Health Plan, does not provide any coverage information publicly.

Recommendations

  • Remove sobriety and prescriber restrictions.
  • 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:

D

Liver damage restrictions

Fee-For-Service (FFS) requires at least moderate liver damage (F2 or greater). Two Managed Care Organizations (MCOs), CareSource and Paramount Advantage, also require at least moderate liver damage (F2 or greater). Two MCOs, Molina Healthcare of Ohio and UnitedHealthcare Community Plan, require severe liver damage (F3 or greater). One MCO, Buckeye Health Plan, has unclear liver damage requirements.

Sobriety restrictions

FFS requires six months sobriety from alcohol and substance use prior to requesting prior authorization. Three MCOs, Buckeye Health Plan, Molina Healthcare of Ohio and Paramount Advantage, also require six months sobriety. One MCO, CareSource, requires three months consecutive abstinence documented by negative urine drug and alcohol screens. One MCO, UnitedHealthcare Community Plan, requires a negative drug screen within the last 30 days.

Prescriber restrictions

FFS requires a specialist to prescribe. Two MCOs, Paramount Advantage and UnitedHealthcare Community Plan, also require a specialist to prescribe. One MCO, Buckeye Health Plan, requires a prescription to be written by or in consultation with a specialist. One MCO, CareSource, requires a prescription by a specialist or a nurse practitioner working with a specialist. One MCO, Molina Healthcare of Ohio, has unclear prescriber requirements.

Recommendations

  • Eliminate liver damage, sobriety, and prescriber restrictions.
  • Improve transparency regarding coverage requirements and create coverage parity across FFS and MCO programs.
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:

D

Liver damage restrictions

Fee-For-Service (FFS) requires most beneficiaries to have moderate liver damage (F2 or greater). Patients co-infected with HIV can qualify without any minimum liver damage requirement. Nine Managed Care Organizations (MCOs) impose the same liver damage requirements as FFS. Columbia Pacific CCO, Health Share of Oregon, Jackson Care Connect, PacificSource Community Solutions Central Oregon and Columbia Gorge Regions, Trillium Community Health Plan, Western Oregon Advanced Health, Willamette Valley Community Health and Yamhill Community Care Organization require the beneficiary to have moderate liver damage (F2 or greater) or be co-infected with HIV. Six MCOs, AllCare CCO, Cascade Health Alliance, Eastern Oregon CCO, InterCommunity Health Network CCO, PrimaryHealth and Umpqua Health Alliance, do not provide hepatitis C coverage requirements publicly.

Sobriety restrictions

FFS inquires about the beneficiary’s alcohol abuse and substance abuse status in the previous six months and the enrollment in substance treatment program if applicable. Nine MCOs, Columbia Pacific CCO, Health Share of Oregon, Jackson Care Connect, PacificSource Community Solutions Central Oregon and Columbia Gorge Regions, Trillium Community Health Plan, Western Oregon Advanced Health, Willamette Valley Community Health and Yamhill Community Care Organization, impose the same sobriety criteria as FFS. Six MCOs, AllCare CCO, Cascade Health Alliance, Eastern Oregon CCO, InterCommunity Health Network CCO, PrimaryHealth and Umpqua Health Alliance, do not provide hepatitis C coverage requirements publicly.

Prescriber restrictions

FFS implements a tiered prescriber specialty requirement: for F4 patients, the treatment must be prescribed by, or in consultation with, a hepatologist, gastroenterologist, or infectious disease specialist; for F3 patients, the treatment must be prescribed by or in consultation with, or the patient has to be in the process of establishing care with, a hepatologist, gastroenterologist, or infectious disease specialist; for F2 patients, the treatment does not need to be prescribed by or in consultation with a specialist.. Nine MCOs, Columbia Pacific CCO, Health Share of Oregon, Jackson Care Connect, PacificSource Community Solutions Central Oregon and Columbia Gorge Regions, Trillium Community Health Plan, Western Oregon Advanced Health, Willamette Valley Community Health and Yamhill Community Care Organization, implement the same prescribing criteria as FFS. Six MCOs, AllCare CCO, Cascade Health Alliance, Eastern Oregon CCO, InterCommunity Health Network CCO, PrimaryHealth and Umpqua Health Alliance, do not provide hepatitis C coverage requirements publicly.

Recommendations

  • Eliminate liver damage, sobriety and prescriber requirements.
  • Ensure parity across FFS and MCO programs and transparency regarding hepatitis C coverage criteria.
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 requires a specialist to prescribe. One MCO, Aetna Better Health, requires a prescription by or in consultation with a specialist. Two MCOs, AmeriHealth Caritas Pennsylvania and Keystone First Health Plan, do not ask for provider specialty. Four MCOs, Gateway Health Plan, Geisinger Health Plan, UPMC For You, and UnitedHealthcare Community Plan, require a specialist to prescribe. One MCO, Health Partners of Philadelphia, has unclear prescriber requirements.

Recommendations

• Eliminate sobriety and prescriber requirements.
• 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:

D

Liver damage restrictions

Puerto Rico does not have any liver damage requirements.

Sobriety restrictions

Puerto Rico requires six months’ sobriety from alcohol and substance use.

Prescriber restrictions

Puerto Rico requires consultation with certain specialists. Mono-infected and co-infected patients are approved for treatment through different processes either by the Department of Health or the AIDS Drug Assistance Program (ADAP). The process is complicated and not transparent.

Recommendations

  • Remove the onerous sobriety and prescriber approval processes.
  • Provide transparency regarding access to hepatitis C medications by posting program criteria and requirements on the hepatitis C program website.
Rhode Island

State of Hepatitis C Medicaid Access:

D-

Liver damage restrictions

Fee-For-Service (FFS) requires at least moderate liver damage (F2 or greater) for patients co-infected with HIV and severe liver damage (F3 and above) for mono-infected patients. One Managed Care Organization (MCO), Neighborhood Health Plan, imposes the same liver damage requirements as FFS. One MCO, UnitedHealthcare Community Plan, requires severe liver damage (F3 or greater). One MCO, Tufts Health Plan, has unclear liver damage requirements.

Sobriety restrictions

FFS requires screening and concurrent alcohol and substance use counseling for beneficiaries actively using. One MCO, Tufts Health Plan, requires screening for active alcohol and substance use. One MCO, UnitedHealthcare Community Plan, imposes different sobriety requirements depending on which Medicaid program (RIte Care or Rhody Health Partners) a beneficiary is enrolled in (30 days abstinence or six months abstinence). One MCO, Neighborhood Health Plan, does not impose sobriety requirements.

Prescriber restrictions

FFS requires a specialist to prescribe and be approved by the Executive Office of Health & Human Services. One MCO, Neighborhood Health Plan, also requires the prescriber to be approved by the state. Two MCOs, UnitedHealthcare Community Plan and Tufts Health Plan, require a specialist to prescribe.

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 a biopsy confirming severe liver damage (F3 or greater) to qualify for treatment.

Sobriety restrictions

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

Prescriber restrictions

South Dakota requires a specialist to prescribe treatment.

Recommendations

  • Remove liver damage, sobriety and prescriber requirements.
  • Maintain transparency regarding hepatitis C coverage requirements.
  • Remove the requirement for a biopsy to assess liver damage and allow for the option of less invasive staging methods.
Tennessee

State of Hepatitis C Medicaid Access:

D

Liver damage restrictions

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

Sobriety restrictions

Tennessee FFS and MCOs require six months sobriety for beneficiaries with a history of alcohol or substance use and confirmation that the beneficiary is either enrolled in or has completed a recovery program, or is receiving counseling.

Prescriber restrictions

Tennessee FFS and MCOs requires a specialist to prescribe.

Recommendations

  • Remove liver damage, 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 require a prescription be written by or in consultation with a specialist.

    Recommendations

    • Eliminate prescriber restrictions.
    • Maintain coverage parity across the Medicaid program and transparency regarding coverage requirements.
    West Virginia

    State of Hepatitis C Medicaid Access:

    C

    Liver damage restrictions

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

    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:

    D+

    Liver damage restrictions

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

    Sobriety restrictions

    FFS and MCOs require beneficiaries with a history of alcohol or substance use to be abstinent six months prior to and during treatment. A patient with a recent history of substance use must be an active participant in a treatment program.

    Prescriber restrictions

    FFS and MCOs do not have any prescriber requirements.

    Recommendations

    • Remove sobriety restrictions.
    • Maintain transparency regarding hepatitis C coverage criteria and continue to exclude prescriptions from MCO contracts to ensure requirements apply to all Medicaid beneficiaries.
    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.