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Effective Date: 



Updated: 3/2018



Allows a physician to request a prior authorization for a refill of antiviral agents for Hepatitis C virus treatments. 



  • This form is only used for people enrolled in Medicaid fee-for-service.
  • Prescribing providers should sign and fax the form to the Texas Prior Authorization Call Center.  The provider should have completed Form 1335, Initial Prior Authorization Request – Medicaid Antiviral Agents for Hepatitis C Virus.



By fax: Texas Prior Authorization Call Center at 866-469-8590



Prescribing providers with questions should call the Texas Prior Authorization Call Center at 877-728-3927.