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Allows a physician to request an initial prior authorization of antiviral agents for Hepatitis C virus treatments.
- This form is only used for people enrolled in Medicaid fee-for-service.
- The form contains three parts:
- Prior Authorization Criteria and Policy
- Contains eligibility requirements, treatment approvals, product information and additional considerations.
- Prescriber Certification of Patient Education for Hepatitis C Treatment
- Contains information about the prevention of liver disease progression, drug treatment processes and information about patient support programs. Signatures of both the prescribing provider and patient are required.
- Initial Prior Authorization Request
- Prescribing providers should read Part I prior to signing the form.
- Prescribing providers should sign and fax Parts II and III to the Texas Prior Authorization Call Center.
- By fax: Texas Prior Authorization Call Center. 866-469-8590
Prescribing providers with questions should call to the Texas Prior Authorization Call Center at 877-728-3927