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Pennsylvania Harsh HCV Medicaid Restrictions TOO
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In evaluating an initial request for prior authorization of a prescription for a Hepatitis C Agent, the determination of whether the requested prescription is medically necessary will take in account the following:
including-
Is prescribed the medication by a specialist (infectious disease, gastroenterology, hepatology, or transplant)
Is prescribed a dose and length of therapy that is consistent with FDA approved labeling
(1) ABSTINENCE: Has a documented history of a pattern of abstinence from alcohol and drugs for at least 6 months prior to treatment.
For a recipient with a history of substance dependence:
--- Has lab testing (such as blood alcohol level [BAL] and urine drug screen [UDS]) that support abstinence
AND
--- Is compliant with treatment if currently being treated for substance dependence
(2) Has a Metavir fibrosis score of F3 or F4 documented
AND
Does not have a history of previously failed therapy for hepatitis C with a treatment regimen that included sofosbuvir (Sovaldi)
AND
Does not have a history of an incomplete course of therapy for Hepatitis C with a treatment regimen that included sofosbuvir (Sovaldi) due to non-compliance with medications and/or Hepatitis C therapy management.
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