Changes to Hepatitis C Prior Authorization (PA) Criteria


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TO:  Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons,    Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes


RE:   Changes to Hepatitis C Prior Authorization (PA) Criteria



Effective October 1, 2022, the Alabama Medicaid Agency will remove the requirement of absence of alcohol and illicit drug use by recipients for the prior approval of antiviral drugs used in the treatment of hepatitis C. A copy of the patient’s drug and alcohol screening lab report will no longer be required. All other criteria remain, including the patient consent form with the patient’s and physician’s signature, which must be submitted with requests.


The updated Prior Authorization (PA) request form and criteria booklet should be utilized by the prescriber or the dispensing pharmacy when requesting a PA. Updated forms and criteria can be found here:


Providers requesting PAs by mail or fax should send requests to:



Medicaid Pharmacy Administrative Services

P.O. Box 3570, Auburn, AL 36831

Fax: 1-800-748-0116

Phone: 1-800-748-0130


Incomplete PA requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the PA form to Kepro. Additional information may be requested. Staff physicians will review this information.


Questions related to this policy update can be directed to the Alabama Medicaid Clinical Services Division at (334) 242-5050.


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