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Effective Date: 




Updated: 3/2018



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:
  1. Prior Authorization Criteria and Policy
  • Contains eligibility requirements, treatment approvals, product information and additional considerations.
  1. 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.
  1. 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