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HCV - Medicaid Pharmacy Program
Criteria & Prior Authorization (PA) Update
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Evidence of Stage 3 or 4 hepatic fibrosis including one of the following
OR
Evidence of extra-hepatic manifestation of HCV, such as type 2 or 3 essential mixed cryoglobulinemia with end- organ manifestations (e.g. vasculitis), or kidney disease (e.g. proteinuria, nephrotic syndrome or membranoproliferative glomerulonephritis). Documentation of the presence of extra-hepatic manifestations based on lab results or imaging results (e.g. CBC, erythrocyte sedimentation rate (ESR)/ C-reactive protein (CRP), urinalysis, BUN/ creatinine and angiography) must be submitted.
OR
HIV-1 co-infection
OR
Debilitating fatigue impacting quality of life
(e.g., secondary to extra-hepatic manifestations and/or liver disease)
Effective October 16, 2014, the fee-for-service (FFS) pharmacy program will implement the following parameters associated with the treatment of Hepatitis C Virus (HCV). The clinical criteria and/or point of service editing below is the result of recommendations made by the Drug Utilization Review Board (DURB) at the September 18, 2014 meeting. Other recommendations made by the DURB at the September meeting will be implemented at a future date.
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