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) 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.
FFS and MCOs do not have sobriety requirements.
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 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.
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.
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.
State of Hepatitis C Medicaid Access:
Idaho requires at least moderate liver damage (F2 or greater).
Idaho requires that a patient not have a history of alcohol or substance use within six months prior to treatment.
Idaho requires that a patient must be under the care of or in collaboration with an experienced hepatitis C practitioner.
State of Hepatitis C Medicaid Access:
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.
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.
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.
State of Hepatitis C Medicaid Access:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require at least moderate liver damage (F2 or greater).
FFS and MCOs have no sobriety restrictions.
FFS and MCOs require a prescription by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
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).
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.
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.
State of Hepatitis C Medicaid Access:
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.
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.
FFS and all 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) 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.
FFS and the five MCOs require beneficiaries to attest that they have not been “actively participating” in substance and/or alcohol abuse.
FFS and the five MCOs impose no prescriber restrictions.
State of Hepatitis C Medicaid Access:
Maine requests a patient’s liver damage but does not stipulate any requirements.
Maine requires six months abstinence from alcohol and drugs.
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 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.
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.
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.
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:
Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require at least moderate liver damage (F2 or greater) to access treatment.
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.
FFS and MCOs require a prescription be written by or in consultation with a specialist. FFS requirements apply across the Medicaid program.
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 requires severe liver damage (F3 or greater).
Montana requires abstinence from drugs and alcohol for at least six months.
Montana requires a prescription be written by or in consultation with a specialist.
State of Hepatitis C Medicaid Access:
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.
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.
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.
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) 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.
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.
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.
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 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.
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.
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.
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:
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.
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.
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.
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) 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.
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.
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.
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 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.
• 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.
State of Hepatitis C Medicaid Access:
Puerto Rico does not have any liver damage requirements.
Puerto Rico requires six months’ sobriety from alcohol and substance use.
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.
State of Hepatitis C Medicaid Access:
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.
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.
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.
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 a biopsy confirming severe liver damage (F3 or greater) to qualify for treatment.
South Dakota requires documentation showing six months abstinence from alcohol and substance use.
South Dakota requires a specialist to prescribe treatment.
State of Hepatitis C Medicaid Access:
Tennessee Fee-For-Service (FFS) and Managed Care Organizations (MCOs) require at least moderate liver damage (F2 or greater).
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.
Tennessee FFS and MCOs requires a specialist to prescribe.
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 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) require at least moderate liver damage (F2 or greater).
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 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.
FFS and MCOs do not have any prescriber requirements.
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.
