Massachusetts insured health plans use a standard form for prior authorization of hepatitis C antiviral therapy. Prescribers meet it when starting or continuing a regimen such as Epclusa, Mavyret, Harvoni or Zepatier for a plan member. Updated with Division of Insurance Bulletin 2024-03, it captures genotype, fibrosis stage, HCV RNA levels and prior treatment response, and includes a step therapy exception section.
The prescribing clinician completes Sections A to F, from destination plan and patient details to clinical information and step therapy exceptions. The clinician or an authorized representative signs in Section C.
Download the current version from the source each time; forms change without notice.
Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The form warns that some plans might not accept it for Medicare or Medicaid requests. It is the standard form for Massachusetts insured health plans under M.G.L. c.176O s.25, so check a public-program member's plan requirements before using it.
It asks whether the patient was previously treated and failed, whether there was an adverse reaction, and for each drug the treatment dates and response: relapse, partial response, null response (under a 2 log reduction in HCV RNA at week 12) or did not complete, with details.