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Provider updates

No Prior Authorization Required for Most Hepatitis C Medications

Dec 16, 2022, 21:14 PM

Changes to the CareOregon Oregon Health Plan (Medicaid) Formulary

Effective January 1, 2023 most hepatitis C treatments will be covered by Oregon Medicaid (including all CCOs) without requiring prior authorization. Two conditions must be met for this to apply 1) the member must be treatment naïve; AND 2) an Oregon Health Plan preferred drug (Mavyret or generic Eplcusa) is being used within usual quantity limits.

Preferred Hepatitis C Drugs

  • Mavyret - Most situations clinically only require 8 weeks. Up to 16 weeks is available without PA.
  • Generic Epclusa - Most situations clinically only require 12 weeks, but up to 24 can be received without PA.

Definition of Treatment Naïve

  • The claims system will look for any evidence of a previous course of therapy with a protease inhibitor.
  • Note: In some cases (such as reinfection or limited first treatment course), it may be clinically appropriate for a second course to be approached as treatment naïve. However, prior authorization will be required if claims see a past treatment.

Case Management

Your office should have received a fax from CareOregon regarding the above information. If you did not receive it, you can download it here.