Prior Authorization is required for hepatitis C treatment. Prior Authorization Submission Requirements are below.
The following MUST be submitted to MedStar Family Choice-DC for a request for hepatitis C treatment to be processed:
- Medical records including:
- Most recent office visit note(s) which includes:
- Detail on all previous hepatitis C treatments; if none, the note must say “treatment naïve.”
- Child-Pugh score (if cirrhotic).
- Social history with detail provided on use of ETOH and/or illicit substances.
- Laboratory studies including:
- a recent (less than 6 months old) baseline viral load.
- fibrosis scoring (FibroSure, FibroTest, FibroScan, liver biopsy).
- (If applicable) HIV viral load and/or hepatitis B viral load.
Submit the completed form and required documentation via fax to 202-243-6258.
Physicians may call MedStar Family Choice-DC at 855-798-4244 for questions or concerns, or fax requests to 202-243-6258.
Information current as of: